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ktULIVED PAYMENT DEC Z 2a1�' RECEIVED S..n Joaquin County-Environmental Health Departn,.„t 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-342P EWIRO� DEC 2 2 Inn NTAL HEALTt _ RERhR Vrf,'F, SAENMRoNMEKT L RECEIVED bV o 12Q1/ E/MRONMExrr,� APPLICATION HEA11 DEPARTMENt7 ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year aotx ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID# 0002983 *Additional Employees State ID#: 39-0100-EH EH ID#: 39000100 Please Note any Corrections or Changes in Facility/Operator lnformati c on this form. Site Name: CCRC FARMS LLC 39-100 Location: 20750 W MANDEVILLE LEVEE RD,STOCKTO Operator: CCRC FARMS LLC e� 1 Mailing Address: PO BOX 248, HOLT CA 9 1, Facility Phone#:(209)464-2959 Legal Owner: CCRC FARMS LLC New Owner? ❑Yes ta No Owner Address: PO BOX 248, HOLT CA 9.5234.s J� M� Owner Phone#:(209)464-2959 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets 3 Number of Showers 3 Number of Lavatories 3 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories from D-L-/0 1 /0I$ to L/3I /aa$ Crop SF Dwellings from _/_/ to / / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 1j U-5 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: tr MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive in portant: 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. Fee Schedule �J Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$15.00 each=$ ❑ 1'ransfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ I.ate Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. ry� Applicant Name Cl'Lt�q (^jafe"be Title Q.4ry'. /t l a ❑ Partnership (Please PRINT or TYPE) I �l El Corporation Address Pa /30� 48 MAVT C& gSa3Y Phone l2A 44 -zySq Applicant Signature Date of Application I27117 Amount Paid Date of Payment Payment Type ec eceipt# Received By Account ID 0002554 ins vb �z� lH� Facility ID Program Record ID PIE Assigned to PWS ID FA0002992 PR0270100 2765 2089-SOOD WA0515717 Report#:7066 Application Printed:10/23/2017