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• Joaquin County-Environmental Health D It <br /> 304 E N enue-Third Floor-Stockton CA 95202- 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Ifousin Camps only) 7 <br /> g p Y) Annual Permit for Calendar Year.' O <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0002797 <br /> Please Nate am,(arrer linn.c or Clarges in 1-aCilitill0p•rator hi rniatian tljj-ec!!p on Nri.r Camp I D#: 39000040 <br /> Site Name: PEARCE,JEFF H 39-40 <br /> Location: 5125 S KAISER RD,STOCKTON <br /> Operator: PEARCE,JEFF H <br /> Mailing Address: 708 GLENHILL CT, NOVATO CA 94947 <br /> Facility Phone#:(415)898-8052 <br /> Legal Owner: PEARCE,JEFF H <br /> New Owner? ❑Yes ONO <br /> Owner Address: 708 GLENHILL CT,NOVATO CA 94947 <br /> Community Facilities Provided by Camp: Community Kitc Owner Phone#:(415)492-4380 <br /> hen: YesMen: Number of Toilets Number of Showers <br /> Women: Number of Toilets Number of lavatories _ <br /> Number of Showers Number of Lavatories _ <br /> Housing Accommodations to be Utilized this Year Occupancy Dates: <br /> Dormitories <br /> Buildings Employees from / /_to_/_/_Crop <br /> — <br /> SF Dwellings from_/ /_to_/ /_Crop <br /> Apartments —T—Owner Owned MH/RV PgyEN I <br /> Owner Owned RR Cars � <br /> 'v Total Number of Days to be used this Calendar Year_ PAY <br /> Total Days Occupied by 25 or more Employees_ EE) <br /> MH/RV Spaces Note:TOTALS Camps occupied by 25 or more employees for 60 or-Qhenn�[` <br /> lyj 14a O� <br /> require a Public Water System P unit. <br /> �I SAN JOAQUIN COUNTY <br /> =J ENVIRONMENTAL <br /> El Inactive DEP Inactive gRTMENT <br /> Important: In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Permanent Camp Annual Permit Fee: Fee Schedule <br /> $35.00+ Number of Employees a <br /> � $12.00 each=$_ <br /> ❑ Orchard Camp Permit Fee: $95.00=$ _ <br /> n[� Transfer of Ownership: $20.00= <br /> El Permit Amendment Fee: <br /> $20.00+ Number of AQtltlional Employees @. $12.00 each=$_ <br /> Late Application Fee: $70.00+ Number of Employees (aj$24.00 each= <br /> Fee must be Qnnitted with Application <br /> TOTAL FEE : <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Enveelolpe $ <br /> MAKE CHECKS PAYABLE TO: PIIS-EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name J c2 n� k�� L.Title ' 0 ,V � <br /> (Please PRINT or TYPE) V ❑Partnership <br /> Address / - — ❑Corporation <br /> C ( �/V�ll� tiGf Phone <br /> Applicant Signature <br /> Date of Application <br /> Amount Pald Date of Payment Payment Type �hec Recei t# <br /> P Received By Account ID <br /> �$a 7S .p v /a 0002366 <br /> Facility ID,,,] Program Record ID PIE <br /> Assigned to PWS ID <br /> 0002805 0270040 2755 -- 347d_-OM <br /> 0002797 <br /> Report#:7066.mt I14 V ! f q <br /> Application Printed:11/19/2003 <br />