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oaquin County-Environmental Health Depart t 600 gain Street-Stockton CA 95202-Phone: 209- '420 PAYMENT R9l9C_ LJ APPLICATION R E C E I VULIN 0 V,3-_yog8 ENVIRONMENTAL HEALTH �d1U PERMIT TO OPERATE SAN JOAQUI EMPLOYEE HOUSING OR LABOR CAMP � FNVI 0 N COUNTY ❑New Camp E]Conditions]Permit E] Multiple Years(Permanent Housing Camps only) Annual Permit for Calenesrr9t ' MAL ❑Amended Permit: *Change of Operator *Change of Owner MENT *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0002983 Please Note any Corrections or Changes in Facility/Operator Information directly on this JCamp ID#: 39000100 Site Name: CCRC FARMS LLC 39-100 Location: MANDEVILLE ISLAND,STOCKTON Operator: CCRC FARMS LLC Mailing Address: PO BOX 248,HOLT CA 95234 Facility Phone#:(209)464-2959 Legal Owner: CCRC FARMS LLC New Owner? ❑Yes ® No Owner Address: 18500 BACON ISLAND RD,STOCKTON CA 95219 Owner Phone#:(209)464-2959 Community Facilities Provided by Camp: Community Kitchen? a Yes ❑ No Men: Number of Toilets 3 Number of Showers 3 Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories 1 5 from 1 / 1 09 to 1 2/3L/200g Crop SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 365 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 0 MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule ® Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ 6 n _ n n ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE S 95.00 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name Clint Womack Title Manager ❑Partnership (Please PRINT or TYPE) El Corporation Address P.O. Box 248 Holt , CA 95234 Phone -209 464-2gcq Applicant SignatureA Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0002554 QD !a- 3' 0� �o2p155 �- Facility ID Program Record ID PIE Assigned to PWS ID FA0002992 PR0270100 2755 208 D N/A Report#:7066.rot Date �� Application Printed:10/30/2008