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ry IOAQUIN COUNTY • PUBLIC HEALTH SEES a ENVIRONMENTAL HEALTH DIVISIO 304 E WEBER AVENUE a THIRD FLOOR • STOCKTON CA 95202 •thone: 209/468-3420 APPLICATION ENRONMENTAL HEALTH (: ' z O VI PERMIT TO OPERATE ,.M,DLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑Annual Permit For Calendar Year rl A mended Permit ❑Multiple Years(Permanent Homing Camps oxtr) neZ • Change of Operator •Change of Owner • Change of Operator Address 0 Change of Owner,Address 983 Additional Employees 00100 Please Note any fbrrec-fians or Ckange_s In Fazfitl7/0perator7wner Inrormadon directly on this form. Site Name: CCRC FARMS LLC 39-100 Location: MANDEVILLE ISLAND — Operator: CCRC FARMS LLC -- — ------- ---- —-- - ---- ------ ----- --------------- --------------------- Mailing Address: PO BOX 24R,IIOLT CA 95234 facility Phone#: 209-464-2959 - - — ---- - ------------------— — --- - — ------- --- - -- —------------------------------------------------------------------------------------ -- - IA*al Owner, CCRC FAR1vIS LLC ;New Owner ❑Yea Fx q u nr:t AkdoreW 18500 BACON ISLAND RD, STOCKTON CA 95219 Owner Phone*: 209-464-2959 � Community Facilities Provided by Cramp: Community KtLchen: 3[Yes ❑Pie Men: Number of Toilets 3 Number of Showers 3 Number of Lavatories-3— Women: Number of Toilets Number of Showers Number of Lavatories iiuusins Accommodatious to be UUllaed this Year: Banff Employees BuEdi►as t Dormitories: 1 12 Owner Owned MF:RV _-- SF Dwellintts Owner Owned RR Can _ Apartments M$'RV Spaces TOTAL of Both COLUMNS I I Occupancy Dates: from -/�/ to�2/ ��c g Cy op Total Number of Days to be used this Calendar Yee- I / l _ Total Days Occupied by 23 or more Employees l from to l ("rep occ ea o 25 or more s or 8D or more so ——— ——— NM: Camp.; up: Y e i o4r yam► require a I'rrolle IfawS,J"W Pena& ❑ Inactive Ineporlant In order to protet vour land use stater,tfcamn will not be used this year but Is tntendedfor aye In Ikefiaxne. Cheek this Box and retun! this aAWks en. fee Schedule 2 Permanent Camp Annual Permit$35 00-Number or Employeesi 12 $12.00 each-$ 179.00 D Orchard Camp Permit Fee=S95.00-S Transfer of Ownership=$20.00=S D Permit Amendment=$20.00+Number of Addtdonal Employees $12.00 each= Late Application Fee$'70.00+Number of Employees — !Lb$24.00 each=$ Fee must be submitted with.Application TOTAL FEE DUE: 179,00 — REnm'TOTAL FEE AS CALCULATED ABOVE IN THE HN(xo&Hp self-addressed ENVELOPE. MAKE CHECKS PAYABLE 70. PI-IS/EHD Applicant agrees to all necessary Inspections Incident to Issuance of a PRRMrr To OPERATE. Applicant agrees that this project(camp).%hall be operated and maintained In accordance with the applicable provisions of the EMPLoYEE Houst*rc ACT.Chapter 1,Parr 1,division 13 of the fleatth and Safety Code and Chapter 1.Subchapter 3,Title 25,California Code ofReplations. Applicant Name CHART.FS r)RMTS TitleMANA ER 0 Partnership 0 Corporation (Please PRINT or TYPE) Address P.O. ROX 24B----14QT.T, Phone 7()Ca 4Fi4-74�j� Applicant Slenature ^--- `'"' '� Date of ADngcatlon IV- -;3�)- j,9 rrograw Record ID# 270100 Facility ID# 002992 Account 11T# 0002364 ea Amount Amount Paid Date pf Payment Payment T Chaa oei tar I Received By1710 LA, Acct A I Fac ID: `— PR;t I PWS IDar I ` P/E: W