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iAN JOAQUIN COUNTY • PUBLIC HEALTR tVICES ENVIRONMENTAL HEALTH DIVISION 304 E WEBER AVENUE a THIRD FLOOR • S OCKTON CA 95202 • Phone: 209/ 6, ��ci[ p ,� ( fP1 V APPLICATION 1l�r _ U ii.� D ENVIRONMENTAL HEALTH N O 1999 PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit Annual Permit For Calendar Year ❑Amended Permit ❑Multiple Years(Permanent Housing Camps only) Date Approved • Change of0perator -Change of Owner ate Malled- • Change of Operator Address • Change of Owner Address Permlt# 002983 • Additional Employees Camp ID# 39000100 Please Note any Corrections or C es in Fac /O erotor/Owner I ornsadon direr on this form. Site Name: CCRC FARMS LLC 39-100 Location: MANDEVILLE ISLAND Operator: CCRC FARMS LLC -------------- --------------------p---------------------------------------------------------------- -�234 - --------------------------------------------------------------------------------------------------------------------. Ma➢ing Address: X�IIQK� ECOUM Facility Phone#: 209-464-2959 - - - --- - - - - ---—- - -- - -- ------------ ----- - - --- — - -- - - - ------ Legal Owner: CCRC FARMS LLC New Owner ❑Yes LXNo! Owner Address: 18500 BACON ISLAND RD, STOCKTON CA 95219 Owner Phone#: 209-464-2959 Community Facilities Provided by Camp: Community Kitchen: IXYes ❑No Men: Number of Toilets 3 Number of Showers 3 Number of Lavatories 3 Women: Number of Toilets Number of Showers Number of Lavatories HousinE Accommodations to be Utilized this Year: Buildines Employees Buildin Employees Dormitories: _ 1 �_ Owner Owned MH/RV SF Dwellings Owner Owned RR Cars Apartments MIi/RV Spaces TOTAL Of Both COLUMNS 0 a Occupancy Dates: from 1 / 1 /00 to 12/ 31/ 00 crop Total Number of Days to be used this Calendar Year 36 from / / to / / Crop Total Days Occupied by 25 or more Employees — --—— Note: Canps occupied by 25 or more emplopees for 60 or more days a year require a Public Wafer System Penxtl ❑ Inactive Imaorlant: In order to protect your land use status,if camp will not be used this year but Is latended far use In Me *tun,Check this Box and return this application. Fee Schedule C$ Perpanent Camp Annual Permit$35.00+Number of Employees 12 $12.00 each=S 179.00 — i ❑ Orchard Camp Permit Fee=$95.00=S ❑ Transfer of Ownership=$20.00=S ❑ Permit Amendment=$20.00+Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee$70.00+Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE: REMIT TOTAL FEE AS CALCULATED.ABOVE IN THE ENCLOSED self-addressed ENVELOPE. AIAAE CHECKS PAYABLE TO: PHS/EHD Applicant agrees to all necessary inspections incident to issuance of a PERmrr 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 Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code ofRt:gnladone. Applicant Name CHART,ES DENNTg Title MANAGER ❑Partnership ❑Corporation (Please PRffCor TYPE) Address P.O. BOX 2 HOLT CA 95234 Phone 209 464-2959 Applicant Signature �"��`---� Date of Application lot`/0"" _ Program Record ID# 270100 Facility ID# 002992 Account lD# 0002554 Amount Paid Date 9f FnMent Payment Type ece t# tgted B Employee#: Acct# Fac ID. PR#: PWS ID#: P/E: I a 7ss