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)aquin County-Environmental Health Depart) <br /> 600 E.o1ain Street-Stockton CA 95202-Phone: 209-46 -3420 7 PA MEN•y <br /> RECEIVFD <br /> APPLICATION NOV 3 0 20 i l <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP HF ENVIIRO ENTAL <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) [X Annual Permit for CaVhJ- eREyJPT0'NT <br /> ❑Amended Permit: *Change of Operator *Change of Owner 7� <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0002983 <br /> *Additional Employees <br /> State ID#: 39000100 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly oil this form. EH ID#: 39000100 <br /> Site Name: CCRC FARMS LLC 39-100 Location: MANDEVILLE ISLAND , 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 K No <br /> Owner Address: 18500 BACON ISLAND RD,STOCKTON CA 95219 Owner Phone#:(209)464-2959 <br /> Community Facilities Provided by Camp: Community Kitchen? M Yes ❑ No <br /> Men: Number of Toilets r Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildinas Emplovees �7� <br /> Dormitories from 1 / 1 ;k12 to1,2- 31 i2. Crop yorl <br /> SF Dwellings from / / to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: �La <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: -�— <br /> MH/RV Spaces 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 @$12.00 each=$ V 1 <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$ <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. <br /> Applicant Name �, Title tti l a rag 2 r ❑Partnership <br /> (Please PRINTP(�. <br /> TYPE) l ❑Corporation <br /> Address1 . ' If o , 9'�2 Phone 2&9 401—A96 <br /> Applicant Signature Date of Application 11- -/t <br /> Amount Paid Date of Payment Payment Type C eck/ ceipt# Received By Account ID <br /> qV " 2 �1 C�` t�' �0 0002554 <br /> Facility ID Program Record ID P/E 1 Assigned to PWS ID <br /> FAA0002992 PR0270100 2765 5 62-WIESEMAN WA0515717 <br /> Repo '/:7 6.rpt ,�/IVZ2Z) Date ��� ,Z Application Printed:10/25/2011 <br />