Laserfiche WebLink
S loaquin County-Environmental Health Departr t <br /> 600 t ain Street-Stockton CA 95202-Phone: 209- 4209 EC1C E I V E D NOV - 3 2009 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH 0v1N COVN <br /> PERMIT TO OPERATE SAN 30A ONMeNFAEN� <br /> EMPLOYEE HOUSING OR LABOR CAMP N"L NDEpA��M <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 21910 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0002983 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this I Camp 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 ONO <br /> Owner Address: 18500 BACON ISLAND RD,STOCKTON CA 95219 Owner Phone#:(209)464-2959 <br /> Cumtuuniiv Facilities Provided by ramp: _Jdwh� Community Kitchen" Xyes ❑ No <br /> Men: Number of Toilets j Number of Showers 3 Number of Lavatories 3 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees ,n <br /> Dormitories �_ �� from /F//Vt0 to IS l31 l 2016 Crop <br /> SF Dwellings from _/_/ to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: Q <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 @$12.00 each=$ b Q' 0 d <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 mast be submitted w:th Applicatior. 'Tt O y <br /> TOTAL FEE DUE$ 6 <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 t t )b Mac � Title ❑Partnership <br /> (Please PRINT or TYPE) El <br /> /� ;� 't I /� Corporation �y <br /> Address V '!�• 1J O�. c�`�(� L`4- C N �l,5 23 Phone 2(�Q_ t�(o�- tq 5 l <br /> Applicant Signature Lz — Date of Application <br /> Amount Paid Date of Payment Payment Type Chec eceipt# Received By Account ID / <br /> -L S- D 0 pq 1 1[O C? v .2p?4 F —) ;t 0002554 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002992 PR0270100 2765 2424-VELO -CACAPIT WA0515717 <br /> Report#:7066.rpt Application Printed:10/14/2009 <br />