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' Paquin County-Environmental Health Depar <br /> Rq�il <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> RFCFJVFQJ <br /> I NUV 2 8 2005 APPLICATION 191% 2�� <br /> ENVIRONMENTAL HEALTH TE N �V�19 Q,�h, 05 <br /> PERMIT TO$Y' EMPLOYEE HOUSING OR LABOR CAMP ��TH F M `-OU <br /> --- � ---- <br /> o q19 NTg4N?3 <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Ye _ <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 Z] No <br /> Owner Address: 18500 BACON ISLAND RD, STOCK ION CA 952 i9 Owncr Phone#:(209)464-2959 <br /> Community Facilities Provided by Camp: Community Kitchen? [(] Yes ❑ No <br /> Men: Number of Toilets 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 <br /> Dormitories 1 8 from 2 / 1/ 06 to12 /31/ 06 Crop <br /> SF Dwellings from _/_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: r� <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: (� <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by or more Employees for 60 more days in a year <br /> Requiree a PUBLIC WATER SYSTEM <br /> 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 _�_ @$12.00 each=$ 96 n n <br /> ❑ Orchard Camp Permit Fee $95.00=$ <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$ 1 31 _ (10 <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,Ti California Cpde of Regulations. <br /> Applicant Name Title ❑ Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address P.O. Box 248 Holt , CA 95234 Phone 209 464-2959 <br /> .Applicant Signature chli rk nenn i c Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 1, d () 2 `2 j 5 / L Q 6 6 0002554 <br /> Facility ID Program Record ID 1 PIE -lAssigned to PWS ID <br /> FA0002992 PR0270100 2755 1, 1084-RAMIREZ N/A <br /> Reoort#:7066.rot � ' I I SaS Application Printed:11/16/2005 <br />