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n Joaquin County-Environmental Health Depr ' tent <br /> t 304 E Wcbc. Avenue-Third Floor-Stockton CA 95202-V 209-468-3420 <br /> 'Y iV1 E N-i- <br /> �,I_.h� <br /> C <br /> APPLICATION ��� <br /> ENVIRONMENTAL HEALTH10 PERMIT TO OPERATE JUL. <br /> EMPLOYEE HOUSING OR LABOR CAMP 3AN JOAOUIN COUNTY <br /> NN ppP�I113,1nIC IIfALIiI SERVICES <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit iorII 9�hltd ali WaVrAl-TH I2IVISION <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 Note ant,Correetiot?s or Changes in Faeilily/nperatnr hi ormalinn directly on this Camp ID#: 39000040 <br /> Site Name: PEARCE,JEFF H 39-40 Location: 5125 S KAISER RD,STOCKTON <br /> Operator: PEARCE,JEFF H <br /> Mailing Address: 708 GLENHILL CT, NOVATO CA 94947 Facility Phone#•(415)898-8052 <br /> Legal Owner: PEARCE,JEFF H New Owner? ❑Yes No <br /> Owner Address: 708 GLENHILL CT, NOVATO CA 94947 Owner Phone#:(415)492-4380 <br /> Community Facilities Provided by Camp: Community Kitchen: LJ Yes <br /> Men: Number of Toilets Number of Showers Number of lavatories <br /> Women: Number of'roilets Number Of Showers Number of lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees from_/_/_to_/_/_Crop _ <br /> Dormitories from_/_/_to_/_/_Crop <br /> SF Dwellings 22 <br /> Apartments �- Total Number of Days to be used this Calendar Year_760 <br /> Owner Owned MH/RV Total Days Occupied by 25 or more Employees—a G <br /> Owner Owned RR Cars Note: <br /> MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year <br /> TOTALS require a Public Water System Permit. <br /> ❑ Inactive <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 /> Fee Schedule // <br /> Permanent Camp Annual Permit Fee: $35.00+ Number of Employees �� a $12.00 each=$ (5 <br /> ❑ Orchard Camp Permit Fee: $95.00=$ <br /> n Transfer of Ownership: $20.00=$ <br /> ❑ Permit Amendment Fee: $20.00+ Number of Additional Employees @ $12.00 each=$_ <br /> Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be Qnnitted with Application <br /> TOTAL FEE DUE: $ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <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 ,Title California25,� if• Code of Regulations. <br /> Applicant Name JC C/� Title t'(J'U El Partnership <br /> (Please PRINT or TYPE) <br /> Address `/�, �I (�,� U(� n y Cl El Corporation <br /> Phone <br /> 1-//f y5 d-y3 40 <br /> Applicant Signature Date of Application <br /> Amount Paid D e o ayment Payment Type Check/Receipt# Received By Account ID <br /> `6 3S .( �7(a3 ✓ d(QSy 0002366 <br /> F=Facility ID lbrogram Record ID PIE Assigned to PWS ID <br /> 0002805 0270040 2755 3474-OM 0002797 <br /> Report#:7066.rot Application Printed:1 1/20120 0 2 <br />