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A � <br /> JAQUIN COUNTY a l't71B1.IC HEALTH SER S <br /> EN%'LRONMENT.11, HEALTH DIVISION <br /> 304 E WEBER AVENIJE a THLRD FLOOR a STOCKTON CA 45202 a Phone: 209'468-3.420 <br /> APPLICATION <br /> FNVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMi'LO`:EE HOUSINC OR LABOR CAMP <br /> ❑New camp LD Conditional Permit yi Annual Permit For Calendar Year <br /> Amended Permit Nfultivie Years(Pcr•manew Ilousinit Camps ot+tr) roped ---- <br /> • Change of Operator •Change ofO%vnrr ate Fit ll prov <br /> • Change of Operotor Address . Clbange of Owner Address <br /> • Additional Employees ,C. ID'm 390—kOO id __J <br /> •Please Note RnyX4rrPedqw nr C h mas in F clll�n/Operatorrowner IKJ6rma&n directly on this form. <br /> -Site Name: PEARCE.JEFF H 39-40 Location: 512 S KAISER RD <br /> Aerator: "' PE 1RCE.JEFF H j <br /> 1'&IIIng Adckel: 708 GL)4;NHILL CT,NOVATO CA 94947 Facility Phone#: 41-"98-8052 <br /> Le>j at Owner: KARCE,JEFF H iAievFOwner . ElYes C Nq <br /> Owlier Address: P O BOX 371,LARKSPUR CA 94977 Owner Phone#: 209-463-1919 <br /> Cult1u1w1itY FaCUIties ProYided by C:alf1D: Community Kitchen: Yes Nu <br /> &lei k: Number of rolleu_-_— Number of Showen_ Number of Lavttlorlea <br /> Women' Number of Toilets Number of Showers Number of Lavatories_____ <br /> Houshld?Accommodations to be L tilisetl this ear: <br /> Buildhiss Employees Oss�er Owned NIB RV <br /> Dormitories: —_— <br /> SF Dwelnn¢x --- Owner Owned RR Cars <br /> Apartments �_ ��_ i4l'rI,R�SQrces _— <br /> OTAL of Both COLIUNIIv <br /> QCcn ancv Dates: <br /> fi,om _! /_to /_i/ crop 1 Total Number of Days to be used tLls Calendar Y'ow <br /> tt-um�/ / to Crop Teal Days Occapled by lS orMenre Employees 1-36- _-� <br /> -— - --- �: i:aargia�xculxGa ay:3 or More eawployce�for of or+wort anlvrsyrar <br /> tegwtc F b&Higer.fysuwtPernt& <br /> �] Irtacth+, im?,orfanf• rn order to nrotect your land use status,tfcarep will not be a m_d this Year but Ir Intended f w ace In free, care (perk this Box and return <br /> thr-applirailon. — <br /> k ce Nchedule <br /> Permanent Ca1np.annual Permit$3!.00+ Nautber of Employees C". r _m 2.00 each- U y <br /> D Orchard Camp Permit Fee=$95.00=S — <br /> 1,-ansfer orownershlp=$20.00=S _---- <br /> LI Permit Amendnie it=MOD+I+i6mber of Additional Employees _(�$12.00 each=$ <br /> Late Appflcation Fee S10.00-=Number of Emplovees _ ri`I>$24.00 each=$ <br /> Fee must be submitted with application TOTAL FEY DLTE: � U <br /> REmT TOTAL FEE AS;CALCULATED ABOVE IN THE ENCLOSED Self-addressed ENVELOPE. MAAM CHEMOPAYABLBTo. PHS/E14D <br /> Applicant agrees to all necessary inspections incident to issuance of a PERNnT TO OPERATR. Applicant agrees that this project camp)shaft <br /> tee nnerate(t and maintained h1 accordance with the anpncable provisions nT the FNM OYES HOMING ACT. (haoter t.Part I.Ptomon 13 of the <br /> Health and Saj24,Code and -¢ter I.Siihrhanter 1.Title?5.C'alftnrnla("Ode orRertllatlonv. <br /> Aslpllcant Nalne - ( --- _ 1-rile G W�`1 L_ U Partnership ❑t'erpetxtiAn <br /> Phase pRlNrf,,T Pll Cry / fli(C C T - ----- Phone Z//J-yy-c/�� 40 <br /> ADnllcant Signature Date of Apniicatlon <br /> rrel}t am Record Al# 270040 F'acuity 11)n 004005 Account U)* 0002366 <br /> FeeAnatmt Ps/id Da yof Flownent Pit-_-yrrtentTyke r ''ieak/Recr`ipttt - --- Received�Bi__ <br /> Employs•9: Accl V. Fhc ID: ' PR:: � PWS IE*. PIE: <br />