Laserfiche WebLink
PLEASE SEND CHECK TO <br /> PAYMENT San Joaquin County-Environmental Health Del—eanem C.C.R.0 FARMS LLC <br /> RECEIVED 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468 <br /> THANK YOU <br /> APPLICATION <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> ENVIRONMENTAL PERMIT TO OPERATE <br /> HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) {S Annual Permit for Calendar Year 20 <br /> 11 <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 /> EH ID#: 39000100 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <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 Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets 3 Number of Showers ?j Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories 5 from 01 /2019 to is/V/MCI 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(� <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: B- <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 /> 5d Permanent Camp Annual Permit Fee $50.00+ Number of Employees 45 @$15.00 each=$ <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$ /oZts•00 <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 r-CA1i (,,)�'f (,��j�, Title /ZGI.►1.t!,k �-4G' ❑ Partnership <br /> (Please PRINT or TYPE) V El <br /> / �t 37/' Corporation <br /> Address �(/ /��jrXs <br /> L� Glro�.c. Phone t1,N)464-.2ci5ri <br /> Applicant Signature Date of Application Jal/O//.$ <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 11 ,O0 //s 2J 0002554 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002992 PR0270100 2765 2089-SOOD WA0515717 <br /> Reoort#:7066 RECEIVED 2 2018 Application Printed:ll/9/2018 <br />