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k -oaquin County-Environmental Health Departs. <br /> pAF—NT 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 <br /> FIECEe © <br /> DEC O 3 2013 APPLICATION <br /> SAN JOAQUIN COUMV ENVIRONMENTAL PERMIT TO OPERATETH R E C E I V 1 1 OCT 2 2 <br /> ENViROMENTAL EMPLOYEE HOUSING OR LABOR CAMP <br /> tiEALTH DEPARTMENT <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year 2014 <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 /> Please Note anv Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000100 <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 ® No <br /> Owner Address: PO BOX 248, HOLT CA 95234 Owner Phone#:(209)464-2959 <br /> Community Facilities Provided by Camp: Community Kitchen? [M 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 /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories 1 5 from0 I_/_GL/2014toL2_/_3_L/2014 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 /> EY Permanent Camp Annual Permit Fet $35.00+ Number of Employees 5 a $12.00 each=$ 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 Oa $12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees a,$24.00 each=$ <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 CHECKS 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 1,Part 1,Division 13 of the California Health and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Corse of Regulations. <br /> Applicant Name Clint Womack Title Manager ❑ Partnership <br /> (Please PRINT or TYPE) <br /> Corporation <br /> Address P.O. Box 248 Holt, CA 95234 Phone 209 464-2959 <br /> Applicant Signature j. .�``/ ',!i— ------- ya� (�o v,� ��� Date of Application <br /> Amount Paid Date of Payment Payment Type !9 eceipt# Received By Account ID <br /> I a `� 0002554 <br /> 4L L <br /> 7FAFacility ID Program Record ID PIE Assigned to PWS ID <br /> 0002992 PR0270100 2765 6219-DUNCAN WA0515717 <br /> Report#:7066 Application Printed:10/17/2013 <br />