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San.loaguin County- Environmental Ilcalll, Delta'uucnl <br /> ! 304 E Weber P ,-Third Floor-Stockton CA 95202-Phone: 4b8-3420 <br /> APPLICATION ENVIRONMENTAL HEALTII t:NVlli0NIwIF f'J I I;ri>Ll I t <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) ®Annual Permit for Calendar Year 2003 <br /> ❑Amended Pcrmit: "Change of Operalor "Change of Owner <br /> *change of Operator Address `Change of owner Address <br /> 'Addilional Employees <br /> Permit IU Jl: 0002983 <br /> Please Note any Corrections or Changes in Facility/Operator Information dir•eclli�air this <br /> 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 il:(209)464-2959 <br /> Legal Owner: CCRC FARMS LLC New Owner? ❑Yes [ No <br /> Owner Address: 18500 BACON ISLANDP.D.STOCitTON CA 95219 Owner Phone fl:(209)464-2959 <br /> Community Facilities Provided by Cantu: Community Kitchen: esNCI3 <br /> Men: Numbcr of Toilets 3 Number of Showers 3 Number of Ia vatoncs <br /> Women: Number of Toilets Numb"of Showers Number of Lavatories _ <br /> Housing Accommodations to be Utilized this Year: Oc cu anc• / / v�r 1 0 11p p <br /> Buildings I;ntployecs from—_ ��� = <br /> Dormitories L from <br /> SF Dwellings Total Number of Days to be used Ibis Calendar Year 365 <br /> Apartments <br /> Total <br /> Owned MHIRV otal Days Occupied by 25 or more Employees 0 <br /> Note: <br /> Owner Owned RR Cars <br /> MH/RV Spaces Camps occupied by 25 or nxrre employees for 60 or nmre.11a_y 1 Jrt a near <br /> 11 <br /> TOTALS require a Public Water System Permit; 1,-,I_ <br /> ❑ Inactive O <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 Jt�O III i hlll.l�4 t <br /> Fee Schedule ��1VIR(�I <br /> 12 $12. <br /> C 00 each-S 179.00 <br /> ElPermanent Camp Annual Permit Fee: $35.00+ Number omployees— <br /> f hand Camp Permit Fee: $05.00=S_ <br /> n�( nTransfer of Ownership: $20.00-$ <br /> Permit Amendment Fee: $20.00+ Number of Adrittional Employees , $12.00 cach=S_ <br /> El <br /> = <br /> Late Application Fee: 570.00+ Number of Employees Q$24.00 each S <br /> Fee must be ulrmitted with Applicatlon TOTAL.FEE I)IIE: S 179.00 <br /> Remit TOTAL FEE; as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PITS-EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees Ihal this project(camp)shall be operated <br /> and maintained in accordance will, the applicable provisions of the EMPLOYEF,HOUSING ACT,Chapter 1,Part 1,Division 13 of the California/Iealth <br /> and Safety Code and Chapter 1,Subchapter 3,'I'itle 25,California Code of Regulations. <br /> Dave Campbell Title Assistant Manager El Partnership <br /> Applicant Name ❑Corporation <br /> (Please PRINT or TYPE) Phone 209 464-2959 <br /> Address P.O. Box 248 Holt, 9 34 <br /> 1. Date of Application2- <br /> Applicant Signature <br /> Amount Pald Date of Payment Payment Type Check/Recelpt# Received By Account ID <br /> I-y �a-L ✓ l 63�5� '2!-G 0002554 <br /> �� <br /> Facility ID Program Record ID <br /> PIE Assigned to PWS ID <br /> 0002983 <br /> 0002992 <br /> 0270100 2755 1084-RAMIREZ <br /> Application Printed:1112012002 <br /> Report#:7066.rpl - L+' lJ <br />