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Joaquin County-Environmental Health Depa it RrEC = ED <br /> 304 E-Weber.- .,enue-Third Floor-Stockton CA 95202-Phob. 209-468-3420 <br /> pt=C 1) 8 2006 <br /> APPLICATION SAN JOAQUIN COumTY. <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Yeah n n 7 <br /> ❑Amended Permit: *Charge 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 thi. 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 No <br /> Owner Address: 18500 BACON ISLAND RD,STOCKTON CA 95219 Owner Phone#:(209)464-2959 <br /> Community Facilities Provided by Camp: Community Kitchen? n Yes ❑ No <br /> Men: Number of Toilets -3 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 <br /> Dormitories from J _/�_/ Q 7 to 1-2 /'kL2_0_0-7 Crop <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 365 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 0 <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by or more Employees for 60 or more days in a year <br /> 1 5 Require <br /> 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 Fee $35.00+ Number ofEmployees �_ @$12.00 each=$ h 0 - Q 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$ 9 5 , OO <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 CCTR C, F,,rM-z T T C ( Title ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address P•0. Box 248 Holt , CA 95234 Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0002554 <br /> 'c15, 0o I�IsIL) L, 1/ 41 1� 159 ✓'� <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002992 PR0270100 2755 1084-RAMIREZ N/A <br /> Report#:7066.rot Application Printed:10/23/2006 <br />