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Sa --aquin County-Environmental Health Depart"' /� I a (V f 304 E Weber i je-Third Floor-Stockton CA 95202-Phone i-468-3420 2 (4 APPLICATION F'^JARoNNIFNIJ M-:[A ENVIRONMENTAL HEALTH P 1/'IT,rlFR I„Fs PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year 2003 ❑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 Camp 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 New Owner? ❑Yes [ No Legal Owner: CCRC FARMS LLC Owner Phone#:(209)464-2959 Owner Address: 18500 BACON ISLAND P.D,STOCKTON CA 95219 Community Facilities Provided by Camp: Community Kitchen: YesN 3 Number of Lavatories 3 Men: Number of Toilets 3 Number of Showers Women: Number of Toilets Number of Showers Number of lavatories _ paOMncY Dates: Housin Accommodations to be Utilized this Year. f� 1/ 0 Buildin Employees from_/_/_to / / Crop Dormitories SF Dwellings Total Number of Days to be used this Calendar Year 36 Apartments Total Days Occupied by 25 or more Employees 0 Owner Owned MHIRV Note: Owner Owned RR Cars MH/RV Spaces Camps occupied by 25 or more employees for GO or more d$yt�t tt`a "r (require a Public Water System PermiE; � 1��r TOTALS L: R ❑ Inactive ON'tc 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 application0AO�tN C R\J\U 1; S�ia1 IG NEAITN SER `i;ytS1 yVIRON Fee Schedule 179.00 12 $12.00 each=$ ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Orchoyees ard Camp Permit Fee: @ $95.00=$ ❑ Transfer of Ownership: $20.00=$ $12.00 each=$_ Permit Amendment Fee: $20.00+ Number of A Tonal Employees $24.00 each=$ ❑ r7 Late Application Fee: $70.00+ Number of Employees Fee must be 9unmitted with Application TOTAL FEE DUE: $ 179.00 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope 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. Dave Campbell Title Assistant Manager ❑Partnership Applicant Name ❑Corporation (Please PRINT or TYPE) Phone 209 464-2959 Address P.O. Box 248 Holt, 9 34 Date of Application /S-,5--O 2- Applicant Signature Amount Paid Date of Payment Payment Type Chec"ecelpt# Received By ;0002554 unt ID PIE Assigned to S ID Facility ID Program Record ID 0002983 0002992 0270100 2755 1084-RAMIREZ Application Printed:11/20/2002 Report#:7066.rpt