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RECEIVED NOV - 8 2010 <br /> .oaquin County-Environmental Health DepartL <br /> 600 L Main Street-Stockton CA 95202-Phone: 209-461, .,420 P�1yMENT <br /> ad RE'c,=IVED <br /> ZI3 "1 APPLICATION DEC 2 3 2010 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit foABr 1 e9f' / <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#: 39000100 <br /> EH ID#: 39000100 <br /> Please Note any Corrections or Changes in Facilitt,lOperator Information directly on this form. <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 No <br /> Owner Address: 18500 BACON ISLAND RD, STOCKTON CA 95219 Owner Phone#:(209)464-2959 <br /> Community Facilities Provided by Camp: Community Kitchen'? Id Yes ❑ No <br /> Men: Number of Toilets 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 /> Buildings Employees ,7 <br /> Dormitories from / 1 12011 to 12 <br /> /3 i /261( Crop <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Y6 5 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: .� <br /> MH/RV Spaces <br /> Note <br /> TOTALS 0 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 a $12.00 each=$ 610, 40to <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 a $12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees a $24.00 each=$ <br /> Fee must be submitted with Application 95 DQ <br /> TOTAL FEE DUE$ i <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self adressed Envelope <br /> MAKE CHECKS PAYABLE to EIID <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall he 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, tie 25,California Code of Regulations. <br /> Applicant Name l iL�n W Q���e Title ❑Partnership <br /> (Please PRINT or, E) ❑Corporation <br /> Address r 0 x L - ' A Phone �o9/�6,41-g . 9 <br /> Applicant Signature Date of Application 1 Z°ZV - 0 v I y <br /> Amount Paid Date of Payment Payment Type CiwcWReceipt# Received By Account lD <br /> 5 r oU a k a e J y 0002554 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0002992 PR0270100 2765 5362-WIESEMAN WA0515717 <br /> Report#:7066.rot Application Printed:11/2/2010 <br />