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�/2-z 7/A'� <br /> S 'oaquin ('ounty- Public Ilealth Services n <br /> Environmental Ilealth Division L ) <br /> 3 <br /> 304 E Weber Avenue-Third Floor-Stockton ('A 95202- Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL,HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> []NvNi Camp ❑ Conditional Permit 1)(.Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> Aniti.ded Permit: *Change or Operator *Change or Owner <br /> *Change or Operator Add- *Change or Owner Address <br /> *Additional Employees <br /> Permit ID#: 0002797 <br /> Please Note anv Corrections or Changes in Facilitt,Operator Information directly I 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 BOX 371,LARKSPUR CA 94977 Facility Phone#: (415)898-8052 <br /> Legal Owner: PEARCE,JEFF H New owner T ❑Yes No <br /> Owner Address: P O BOX 371,LARKSPUR CA 94977 Owner Phone#: (209)4e3.-t919 <br /> Community Facilities Provided by Camp: Community Kitchen: UYes U No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of'Ibilcts Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees from_/_/_to_/ / Crop_ <br /> Dormitories from_/_/_to_/ / Crop_ <br /> SF Dwellings <br /> Apartments Total N urn her of1)aystobeusedthinCalendarYear _ <br /> Owns' Owned M H/RV Total Days Occupied by25 or more Employees J' <br /> Owner Owned RR Cars <br /> 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 /> loactive <br /> Im portan : In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Cheek this Box and return this application. <br /> Fee Schedule <br /> ❑Pet nianent Camp Annual Permit Fee: $35.00 + Number of Employees �'� (� $1r200 each <br /> --z—w ❑ Orchard Camp Permit Fee: $95.00=S <br /> " <br /> ❑ Transfer of Ownership: $20.00=$ <br /> ❑ Per mit Amend menitS Fee. $20.00 r Numhcr of Additional Employees @ $12.00 each=S <br /> ❑ Late Application Fee: $70.00 Number ofEmployccs n $24.00 each=S <br /> Fee must be submitted with Application - <br /> TOTALFEE DUE: s <br /> RemitTOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLETO: PHS-EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall <br /> operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1,Part 1, Division 13 of th <br /> California lleadh and Safety Code and Cha _��r^1,Subchapter 3,Title 25,California Code of Kegulatious <br /> —~ / � �' C�' A",-,= / ElPartnersNp <br /> Applicant Name _. �:.I ✓ / ��t=.L Title L <br /> (Please PRINT or TYPE) ❑Corporation <br /> / � �- r C -• X l <br /> Address w C' �L �.__ ��;, �/ 'rT�; C,'� I y / t Phone <br /> Applicant Signature 1� -V l < t Date of Application <br /> Ar:Iount Paid Date of Paviaent Payment Type Check/Receipt# Received By Account ID <br /> 3 (J I / J , Q()iJ / 0002366 <br /> Facility ID rogram Record ID P/E ll / Assigned to PWS ID <br /> 0002805 0270040 2755 0631 -AUJUARD 0002797 <br /> Report s•7066.rpi �►/_ _ % O� ?/Z1 Application Printed:1117/00 <br />