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QWP'* San Joaquin County-Environmental Health Department 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 TO 0 2C�? N,OP Ey.TP APPLICATION pERNIITjS SAL H�L a' TH P. V�Ro R�M��1S ENVIRONMENTAL HEALTH ID ERVICES EN PP PERMIT TO OPERATE HF�,�ZH EMPLOYEE HOUSING OR LABOR CAMP 1 -O mp.:New Ca ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) /�Annual Permit for Calendar Year aOZ1 tAmended Permit: "Change of Operator 'Change of Owner *Change of Operator Address "Change of Owner Address Permit ID#: 0002983 Y' "Additional Employees State ID#: 39-0100-EH EH ID#: 39000100 Please Note tiny Corrections or Changes in Facility/Operator Information directly on this form. Site Name: CCRC FARMS LLC 39-100 Location: 20750 W MANDEVILLE LEVEE RD,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 I Owner Address: PO BOX 248,HOLT CA 95234 owner Phone n:,'209)4t34-2959 i Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets 3 Number of Showers 3 Number of Lavatories 3 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupanev Dates: Buildings Employees Dormitories from 0) /A/�to/4 1_1 "_1 Crop SF Dwellings from_/ / to_/ / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 9 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 Fee $50.00+ Number of Employees S @$15.00 each=$ ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application / TOTAL FEE DUE$ /Z UU 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,Su chapter 3,Title 25,California Code of Regulations. Applicant Name 1 W " a Title 'K.f` rA ❑Partnership (Please PRINT or TYPE) ❑Corporation Address A) Phone k0i Qs,µ-2tiSG 1 Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0002554 Facility ID Program Record ID (I P/E J Assigned to PWS ID FA0002992 PR0270100 2765 9834-SUSZYCKI WA0515717 Report#:7066 Application Printed:11/19/2020