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PAYMENT <br /> S. aquin County-Environmental Health Departn RECEIVED <br /> 1868 E.hazelton Avenue-Stockton CA 95205-Phone: 209- - -3420 JAN 2 O 201C <br /> J <br /> HECK RONMEWALL <br /> OkLAPPLICATION TH DEPAR111EW <br /> ENVIRONMENTAL HEALTH RECEIVED OCT 2 0 2014 <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) 129 Annual Permit for Calendar Year 2015 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0002983 <br /> *Additional Employees <br /> State ID#: 39-0100-EH <br /> EH ID#: 39000100 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: CCRC FARMS LLC 39-100 Location: 20750 W MANDEVILLE LEVEE RD,STOCKTO <br /> Operator: CCRC FARMS LLC <br /> Mailing Address: PO BOX 248, HOLT CA 95234 Facility Phone#:(209)464-2959 <br /> Legal Owner: CCRC FARMS LLC New Owner? ❑Yes Q No <br /> Owner Address: PO BOX 248, HOLT CA 95234 Owner Phone#:(209)464-2959 <br /> Community Facilities Provided by Camp: Community Kitchen? ® Yes ❑ No <br /> Men: Number of Toilets 3 Number of Showers 3 Number of Lavatories 3 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Ilousin2 Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildimz Employees <br /> Dormitories 1 5 fromOL/_n/ 2ffl 5to12_tJJ t ] Crop <br /> SF Dwellings from / / to /_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 365 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 0 <br /> MH/RV Spaces <br /> Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Important: 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. <br /> Fee Schedule <br /> ❑: Permanent Camp Annual Permit Fe( $35.00+ Number of Employees 5 @$12.00 each=$ 60.00 <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $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 <br /> TOTAL FEE DUE$ 95.00 <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CIIECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter I, Part 1, Division 13 of the California Health <br /> and Safety Code and Chapter I,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Craig Watana Title General Ranch Manager ❑ Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address P.O. Box Ho Phone 209 464-2959 <br /> Applicant Signature Craig Watanabe Date ol'Application 2- 31- 201-I <br /> Amount Paid Date of Payment Payment Type Check/5ceipt# Received By Account ID <br /> C3�60 I J / 6 O d 0002554 <br /> Facility ID Program Record ID (/ PIE Assigned to PWS ID <br /> FA0002992 PR0270100 2765 6219-DUNCAN WA0515717 <br /> Report#:7066 Application Printed:10/15/2014 <br />