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-AN JOAOUIN COUNTY • PUBLIC HEALTH <br /> ENVIRONMENTAL HEALTH DIVISL LICES <br /> 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH �t <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit Annual Permit For Calendar Year <br /> ❑Amended Permit ❑Multiple Years(Permanent Housing Camps oily) M# OO�2797 <br /> — <br /> • Change of Operator *Change of Owner <br /> • Change of Operator Address • Change of Owner Address <br /> • Additional Employees 00040 <br /> Please Note anj Corrections or C es in Far' /O eratoriOwner In ormadon dh•ec on this form <br /> Site Name: PEARCE,JEFF H 39-40 Location: _ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- <br /> Operator: PEARCE,JEFF H <br /> Mailing Address: PO BOX 371,LARKSPUR CA 94977 Facility Phone#: 415-898-8052 <br /> - —------- -- ---- --- -- — --- — - ----- -— - ----- <br /> ----—- --- ----- ----— ---- -- — - -- ------------------ - <br /> Legal Owner: PEARCE JEFF H New O ❑Yes U.Oo \\ <br /> Owner Address P O BOX 371, LARKSPUR CA 94977 Owner Phone#: � <br /> Community Facilities Provided by Camp: Community Kitchen: ❑ Yes KNo <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: <br /> Buildinss Employees B <br /> Dormitories: Owner Owned MH/RV <br /> SF Dwellings Owner Owned RR Cars <br /> Apartments MH/RV Spaces <br /> TOTAL Of Both COLUMNS�7 <br /> Occupancy Dates: �,/► <br /> fro-OL—la'/�to 7—ly Oa crop 4 r Total Number of Days to be used this Calendar Year <br /> from / / to / i Lynp Total Days Occupied by 23 or more Employees <br /> ——— ——— Note: Camps occupied by 23 or more employees for 60 ormort dayr a year <br /> requi re a Pab9c Water System Permit. <br /> ❑ Inactive Imoor t In order to protect your land use status,if camp mfi not be used this year but ishatendedfor ase his theft wie,Ckeek this Box and return <br /> this appUuadow <br /> Fee Schedule �- <br /> ❑ Permanent Camp Annual Permit$35.00+Number of Employees - Z3 $12.00 each=$ <br /> ❑ Orchard Camp Permit Fee=$95.00=$ <br /> ❑ Transfer of Ownership=$20.00=$ <br /> ❑ Permit Amendment=$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 submitted with Application TOTAL FEE DUE: <br /> REMrr TOTAL FEE AS CALCULATED ABOVE IN THE ENCLOSED self-addressed ENVELOPE. JV4KE CHECKSPAYABLE 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 <br /> be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUMG ACT,Chapter 1,Part 1,Division 13 of the <br /> Health and Safely Code and Chapter 1,Sub5b pter 3,Tide 25,California Code ofRegulations. <br /> Applicant Name ��""Title BwN4A— ❑Partnership ❑Corporation <br /> (Please PRINPor TYPE] Address �� 3 $Pei Phone /f e at9 cCS Z_ <br /> Applicant Signature Date of Application <br /> Program Record ID# 270040 Facility ID# 002805 Account ID# 0002366 <br /> Amount Paid Da 91 pawwtpayment T ecelpt At Re ed <br /> .pv iso� 3 <br /> Employee It Acd#: ac ID: PR#: PWS IDA <br />