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n Joaquin County-Public Health Services <br /> PAYMEN f Environmental Health Division <br /> RECEIVED 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> DEC 12 2001 APPLICATION 2001 <br /> ENVIRONMENTAL HEALTH <br /> SAN JOAQUIN COUNTY PERMIT TO OPERATE <br /> PUBLIC HEALTH SERVICF c EMPLOYEE HOUSING OR LABOR CAMP <br /> :'.;R0NP;IFNTAI HFAITH F". <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) IN Annual Permit for Calendar Year 2002 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change or Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0002983 <br /> E <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this 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: EIYesNCI <br /> Men: Number of Toilets 3 Number of Showers 3 Number of lavatories 3 <br /> Women: Number of Toilets Number of Showers Number of lavatories _ <br /> Housine Accommodations to be Utilized this Year: Occu anc llates: <br /> Buildings Ems from_I_/OAo 12tiiVZ Crop _ <br /> Dormitories 1 L from_/_/_to_/_/_Crop <br /> SF Dwellings <br /> Apartments Total Number of Days to be used this Calendar Year_65 <br /> Owner Owned MH/RV Total Days Occupied by 25 or more Employees 8 <br /> Owner Owned RR Cars Note: <br /> MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year <br /> TOTALS require a Public Water System Permit. <br /> I� 12 <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 of Employees 12 @ $12.00 each=$ 179.00 <br /> ❑ Orchard Camp Permit Fee: $95.00=$ <br /> Transfer of Ownership: $20.00=S <br /> Permit Amendment Fee: $20.00+ Number of A;;ional Employees @ $12.00 each=$_ <br /> El <br /> i Late Application Fee: $70.00+ Number of Employees @$24.00 each=S <br /> r-- <br /> Fee must be Ss bi mitted with Application 179.00 <br /> TOTAL FEE DUE: S <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PHS-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 David Campbell Title Assistant Manager ❑Partnership <br /> (Please PRINT or TYPE) /l �O 8 c�77 7ElCorporation <br /> Address P.O. Box 248 �`�j(/ Phone 209 464-2959 <br /> Applicant Signature Date of Application-ME <br /> Amount Paid Date of Payment PaymenlType Check/Recelpt# Received By Account ID <br /> I q - z�1z ✓ '� 5443 0002554 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0002992 0270100 2755 1084-RAMIREZ 0002983 <br /> Report#:7066.rot Application Printed:11/19101 <br />