Laserfiche WebLink
San Joaquin County-Public Health Services <br /> Environmental Health Division <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> APPLICATION i 2 <br /> ENVIRONMENTAL HEALTH . _l l J CUU <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <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 an)-Corrections or Changes in Facility/Operator Information 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: P-O 893E-37+74=AR 8PJ 1R-CA-94977 7D$� i Facility Phone#:(415)898-8052 <br /> Legal Owner. PEARCE,JEFF H <br /> / C 7 Vl`1 N .7 New Owner? ❑Yes ❑ No <br /> owntr Addre. : O /a�S-2-�?; -?448ut'c'-^2-r.�u7� Owner Phone <br /> _Community Facilities Provided by Camp: Community Kitchen: YesN <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories _ <br /> Ilousina Accommodations to be utilized this Year: Occupancy Dates: <br /> Buildings Employees from o/L/_0Uo 1 Z/_X/jgarop � <br /> Dormitories from_/_/_to_/_/_Crop <br /> SF Dwellings r <br /> Apartments 1 A .2 Total Number of Days to be used this Calendar Year J <br /> Owner Owned MH/RV Total Days Occupied by 25 or more Employees--3 (1-1 <br /> Owner Owned RR Cars Note: <br /> '^ MHIRV Spaces Camps occupied by 25 or more employees for 60 or more days in a year <br /> TOTALS require a Public Water System Permit. Lo 11� <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 /> I`q'f Permanent Camp Annual Permit Fee: $35.00+ Number of Employees C $12.00 each=S 3 <br /> "st ❑ Orchard Camp Permit Fee: $95.00=$ <br /> n Transfer of Ownership: S20.00=S <br /> t Permit Amendment Fee: $20.00+ Number of A�Tdllional Employees C' $12.00 each-S_ <br /> ❑ <br /> Late Applicatinn Fee: 570.00+ Number of Employees C$24.00 each=S <br /> �I Fee must be Qmitted with Application 3- J_d V <br /> TOTAL FEE DUE: S - <br /> Remit"TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PHS-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,I' of the California Flealth <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> c � <br /> 1 O��'�� Title ��(J iV� � El Partnership <br /> Applicant Name ----.=��111 <br /> (Please PRINT or TYPE) qy� ❑Corporation <br /> Address —20 �L-� C U k4" �j 7 Phone �r f ys�-y3�Pd <br /> o Date of Application 0 2 <br /> Applicant Signature j —� e— <br /> Amount Paid Date of Payment Payment Type Check/ ceipt# Received By Account ID <br /> 0002366 <br /> �33S•�� -� -� CN ec� �YS 7 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0002805 0270040 2755 3474-OM 0002797 <br /> Reoort#.7066.rot r` V t ` Application Printed 11/19/01 <br />