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PAYMENT <br /> RECEIVED <br /> San.Joaquin County-Environmental Health Department <br /> APR 11 2022 <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> cA�I Inn <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year t?,62,2 <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 Mis form. <br /> Site Name: CCRC FARMS LLC 39-100 Location: 20750 W MANDEVILLE LEVEE RD,STOCKTON <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 Im 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 ?, 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 _ from d /QLAM to Le I, Crop <br /> SF Dwellings from / / to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3(� <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: I <br /> MH I RV Spaces Note I <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 Fee $50.00+ Number of Employees @$15.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application <br /> RECEIVED MAR 14 ?n21 TOTALFEEDUES I2S dU <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 <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. ` I- <br /> Applicant Name Cray wG�' oy4 Title �G,t' c k Vvlan !g±:f ❑Partnership <br /> (Please PRINT or TYPE) N �� El Corporation <br /> Address V b v^ q'g--6 � Phone (yg) <br /> Applicant Signature Date of Application �3/�472 <br /> f , <br /> Amount Paid Date of Paym ant Payment Type Check/Receipt# Received By Account ID <br /> �, zZ ck 3/03 0002554 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002992 PR0270100 2765 9834-SUSZYCKI WA0515717 <br /> Report# 7066 Application Printed:3/24/2022 <br />