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Joaquin County-Environmental Health Depa, it 7" 304 E Web. venue-Third Floor-Stockton CA 95202-Pht. 209- PAYMENT 468-3420 PAYMENT RECEIVED W , APPLICATION DEC 17 2003 ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTALHEALTH DEPARTMENT ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year 2004 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0002983 Please Note any Corrections or Changes in Facility/Operator Information directly on this ICamp ID#: 39000100 Site Name: CCRC FARMS LLC 39-100 Location: MANDEVILLE ISLAND,STOCKTON Operator: CCRC FARMS LLC Mailing Address: PO BOX 248, HOLT CA 95234 Facility Phone#:(209)464-2959 Falwner: CCRC FARMS LLC New Owner? ❑Yes ® No Owner Address: 18500 BACON ISLAND RD,STOCKTON CA 95219 Owner Phone#:(209)464-2959 Community Facilities Provided by Camp: Community Kitchen: J&J Yes NLJ 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: Occupancy Dates: Buildings Employees from_L/_L/Q4to]2(3104 Crop _ Dormitories 1 8 from_/_/_to_/_/_Crop _ SF Dwellings Apartments Total Number of Days to be used this Calendar Year 365 Owner Owned MH/RV Total Days Occupied by 25 or more Employees 0 Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS 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: $35.00+ Number of Employees 8 @ $12.00 each=$ 96,. 13/. O0 ❑ Orchard Camp Permit Fee: $95.00=$ nn Transfer of Ownership: $20.00=$ El Late Amendment Fee: $20.00+ Number of Additional Employees @ $12.00 each=$_ Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ cee must be Qrnitted with Application TOTAL FEE DUE: $ 9�:�O f aS( •D e> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope 7 MAKE CHECKS PAYABLE TO: PHS-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,Subchapter 3,Title 25,California Code of Regulations. Applicant Name Dave Campbell Title A,;Gi G .ant Manager ❑ Partnership (Please PRINT or TYPE) ❑Corporation Address P.D. Box 248 Holt, CA 9523 Phone 209 464-2959 Applicant Signature Date of Application �oC�is/o3 Amount Paid Date of Payment Payment Type ea eceipt# Received By Account ID t I. 1 0002554 13 S. — 1 / lu 104 85 L6. Facility ID Program Record ID PIE Assigned to PAIS ID 0002992 0270100 2755 1084-RAMIREZ 0002983 Report#:7066.rot Application Printed:11/19/2003