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aquin Co- y-Fuvironmental Health Depart PAYMENT <br /> 304 E Weber iue-Third Floor-Stockton CA 95202-Phon— �9-468-3420 <br /> RECEIVED <br /> NOV 1 7 2004 APPLICATION DEC 1.7 2004 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> HEALTH DEP <br /> nMr <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 1002983 <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 ® No <br /> Owner Address: 18500 BACON ISLAND RD,STOCKTON CA 95219 Owner Phone#:(209)464-2959 <br /> Community Facilities Provided by Camp: Community Kitchen? []k Yes ❑ No <br /> Men: Number of Toilets Number of Showers 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 1 /1_/0 5 to1.2 /3_1_/_0_5_ 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: n <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 8 @$12.00 each=$ 96 . 00 <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$ 131 .00 <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 Charles Dennis Title Manager ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address nx t CA 95234 Phone 209 464-2959 <br /> Applicant Signature = Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0002554 <br /> $ /3l. oo l9/i-7/DV ✓ 7g3(o (16 <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:10/29/2004 <br />