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`PAYV EN I <br /> RECEIVED 40an Joaquin County-Public Health Services <br /> Environmental Health Division <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 r� �l <br /> SAN JOAQUIN COUNTY APPLICATION �r^� r� Itl 2 6 200� <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH —� L U <br /> !YIRONA4ENTHL HEALTH DIVIS' PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP —————————————— <br /> ElNew Camp ❑ Conditional Permit ❑ Nlultiple Years(Permanent Housing Camps only) INAnnual Permit for Calendar Year 2002 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0002983 <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: YesN 3 <br /> Men: Number of Toilets 3 Number of Showers 3 Number of lavatories <br /> Women: Number of Toilets Number of Showers Number of lavatories _ <br /> Housin¢Accommodations to be Utilized this Year:. Occu anc Dates: <br /> Buildings Ems from_/_/UAo 12t3102 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 <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 /> ❑ 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 /> oPermanent 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: $20.00=$ <br /> Permit Amendment Fee: $20.00+ Number of Additional Employees @ $12.00 each=$_ <br /> ❑ <br /> Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be t�i mitted with Application 179.00 <br /> TOTAL FEE DUE: $ <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) ❑Corporation <br /> Address P.O. Box 248 <br /> Phone 209 464-2959 <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment PaymenfType Check/Receipt# Received By Account ID <br /> 0002554 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0002992 0270100 2755 1084-RAMIREZ 0002983 <br /> Reoort#:7066.rot Application Printed:11/19/01 <br />