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San Joaquin County-Public Health Services Environmental Health Division 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑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 Legal Owner: 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: Yes NL] Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees from_/_/_to_/_/_Crop Dormitories from_/_/_to Crop SF _ SF Dwellings Apartments Total Number of Days to be used this Calendar Year_ Owner Owned MH/RV Total Days Occupied by 25 or more Employees 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 @ $12.00 each=$ ❑ Orchard Camp Permit Fee: $95.00=$ Transfer of Ownership: $20.00=$ ❑ Permit Amendment Fee: $20.00+ Number of Agional Employees @ $12.00 each=$_ Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ Fee must be Qa mitted with Application TOTAL FEE DUE: $ 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. Applicant Name Title ❑Partnership (Please PRINT or TYPE) ❑Corporation Address Phone Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0002554 Facility ID Program Record ID PIE Assigned to PWS ID 0002992 0270100 2755 1084-RAM IREZ 0002983 Report#:7066.rot Application Printed:11/19/01