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tt ,% PAYMENT San Joaquin County-Public Health Services RECEIVED Environmental IIealth Division 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 APPLICATION SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH PUBLIC HEALTH SERVICES PERMIT TO OPERATE ENVIRONMENTAL HEALTH DIVISION EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only)f[]Annual Permit for Calendar Year 2001 ❑Amended Permit: 'Change or Operator `Change or Owner 'Change of Operator Address 'Change of Owner Address *Additional Employees PermitID#: 0002983 Please Note wry Corrections or Changes in Facility/Operator Information directly Camp ID#: 390001/0 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 No Men: Number of Toilets 3 Number of Showers _ Number of Lavatories 3 Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees from 1/ I lAto I2/ CroP IfJe �►' �` Dormitories from_/_/_to_/ / Crop SF Dwellings Apartments Total Number ofDays to be used this Calendar Year_365 Owner OwnedMH/RV Total DaysOccupledby25or more Emplo)tes 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 12 @ $12.00 each=$ 179.0o ❑ Orchard Camp Permit Fee: $95.00=S ❑ Transfer of Ownership: $20.00=s ❑ PermitAmendment Fee: $20.00+ Number of Additional Employees @ $12.00 each=S ❑ Late Application Fee: $70.00+ Number of Employees @ $24.00 each=S Fee must be submitted with Application TOTALFEE DUE: S 179.00 RemitTOTAL 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 operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1,Part 1, Division 13 of th California Heahh and Safely Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulatious Applicant Name Charles Dennis Title M_aneciPr ❑Partnership (Please PR/Nr or TYPE) ❑Corporation Address P.O. Box 248 Holt, CA 95234 Phone20g 464-2g59 Applicant Signature — —Y Date of Application Amount Paid Date of Payment Payment Type Check/ eceipt# Received By Account ID 0002554 "TT77- - l (-3�- c(." C t �K I`f s ��1 Facility ID Program Record ID P/E Assigned to PWS ID 0002992 0270100 2755 1084-GALAPIA 0002983 .. q-, . `,,7JW