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� r r t S JOAQUIN COUNTY • PUBLIC IIEALT ZRVICES ENVIRONMENTAL HEALTH DIVISION 304 E WEBER AVENUE• THIRD FLOOR• STOCKTON, CA 95202syr6Fi5 209i468-3420 'r�'��.4f �,t (n� p44q-7( APPLICATION JAN 1 21998 ENVIRONMENTAL HEALTH PERMIT TO OPERATE k "'1`�UiN COUNTS• EMPLOYEE HOUzING OR LABOR CAMP SERVICES ")'W tt NTr L h- u New Camp u t onditioual Pern ik a Annual Permit.For C ent q�r VfS!(tB9 `i Amended Permit a Multiple Years(Permanent Housing Camps 00{v) ate Approved —Change of Operator- —Change of Owner Rate Mailed: —Change of Operator Address —Chanue of Owner Address jpormit# 002797 —Additional Employees "mp ID# 39-04a Please Note any Corrections or Changes in Fac&&V,'OpertdoNOn ner InjbmunYon directly on this form. -- -- - - -------------------------- --------------------- -- --— - ------ --- ----------- -- ----- ----- - -----------------I----------- Site Name: PEARCE,JEFF H 3940 Location: 5125 S KAISER RD ___----------- ---- --------- ---__----- ---------------- _---------------------------------------------------------- -__-------- ---------- ------------ ------------ ----------- -__---- --------- ---------_-_-_-____-____- Operator: PEARCE,JEFF H — NOVATO - ------- -- - - I Mailing Address: 708 GLENHILL CT,NOVATO CA 94947 l''acility Phone#: 415-898-8052 Legal Owner: PEARCE,JEFF H ew Ownet �7 Yes INq --- -- -- - - — _. y�s-8y8 dos L� Owner Address: P O BOX 371,LARKSPUR CA 94977 Owner Phone#: i919 --J -------------------------------- —--------------------------------------------------------------- Community Facilities Provided by Camp: Community Kitchen: ❑you U No Men: Number of Toilets Number of Showers Number of Lavatorles Women: Number of Toilets Number of Showers Number of Lavatorles Ilousinl;Accommodations to be Utilized this Year: Buildings Employees Bulldin�s Employ Dormitories: Owner Owned NM,RV SF Dwellinp Owner Owned RR Cars Apartments _1 MHIRV Spaces TOTAL of Both COLUMNS Occupancy Dates: from /_/_to_/_�_ Crop Total Number of Days to be used this Calendar Yea], from / to / / Crop Total Days Occupied by 25 or more Employees L_—) ----- — — ---—— --- Note: i zv s occz,i ed by 23 or more emidoyees fa-60 or more dgrs•a year require a Pmbdie MWr System Permui ❑ Inactive Importard: !n order to protect vour land use status,ifcamp will not be ussd this vear but Is intended for use&r the fidure. Check this Box and return this appikation. Fee Schedule F FI Permanent Camp Annual Permit$35.00+Number of Employees -3 n$12.00 each=$ Orchard Camp Permit Fee=$95.00 $ ❑ Transfer of Ownership=$20.00 $ Permit Amendment=$20.00+Number of additional Employees $12.00 each= ❑ Late Application Fee$70.00+Number of Employees (a),$24.00 each=$ Fee must be submitted with Application TOTAL.FEE DUE: RFnnz ToT_aLFEE AS cALCLLATID ABOVE L1 THE ENCLOSED self-addressed ENVELOPE. A1AItT CHECJISP9Y.4ELErTO: PHS�H� t necessary hnrctions incident co issuance oa a PSR11nr To OPERAlb Applicant agrees that this p►nject(camp)shag be ant agrees ct+rtiiaet'e with the applicable provisions of the F-WLOYEE HOt�srta ACT, Chapter 1.Pt"1,Division 13 Nth ArpfJjj(, to a opereiP'i Attd m�ter 1.Sa�aPter 3,'fide>K,Calffo Cwis mf Rtgwkli'onv. vA Sa m'Coot 412eiE prut Nome it&mt pru►t � ft Wt l C I • If- 64- �' C( 7 - �I011t' �� intSlgnaRTe aid Date of —Pay-terttTV