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)aquin County-Environmental Health Dep PAYMENT <br /> 1868 L.Hazelton Avenue-Stockton CA 95205-Phone:02t -46oi-3420 <br /> RECEIVED <br /> 9 <br /> APPLICATION DEC 3 1 2019 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> HEALTH DEPART T r„ <br /> ❑New Camp []Conditional Permit El Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year t%�'.-" <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID# 0002983 <br /> *Additional Employees <br /> State ID#: 39-0100-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000100 <br /> Site Name: CCRC FARMS LLC 39-100 Location: 20750 W MANDEVILLE LEVEE RD,STOCKTO <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: PO BOX 248, HOLT CA 95234 Owner Phone#:(209)464-2959 <br /> Community Facilities Provided by Camw Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets 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: Occupancy Dates: <br /> Buildings Emolovices <br /> Dormitories j `j from 0 1/_/?=to L/ / iD Crop <br /> SF Dwellings from / / to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3(o j <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: �} <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 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 /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees `D @$15.00 each=$ --7 s d U <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ /ZS•t70 <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to 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 V Y(^4 Wa--r -'Ak, Title �(ryik I"la1'LC "fx ❑ Partnership <br /> (Please PRINT or TYPE) // ❑Corporation <br /> Address PO p��- r'LS� 4 Phone <br /> Applicant Signature Date of Application <br /> 1 <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By i Account ID <br /> AP p,l'I� O�O I m� � 0002554 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002992 PR0270100 2765 9834-SUSZYCKI WA0515717 <br /> Report#:7066 Application Printed:11/13/2019 <br />