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San Joaquin County-Environmental Health Department PAYMENT <br /> RECEIVED <br /> 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH DEC 3 1 2025 <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP SAN JOAQUIN COUNTY <br /> ENVIRON AL <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit f111MIM 11YE ENT <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> State ID#:39-0100-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on thisform. <br /> Site Name: CCRC FARMS LLC 39-100 Location: 20750 W MANDEVILLE LEVEE RD STOCKTON <br /> Operator: CCRC FARMS LLC 39-100 Email: <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 Email: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets 4 Number of Showers 1 Number of Lavatories 3 <br /> Women: NumberofToilets Number of Showers Number of Lavatories <br /> Housin¢Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from -P//'N /2` to I2/3//26 Crop <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <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 tlris Box and return this application. <br /> Fee Schedule _ <br /> Permanent Camp Annual Permit Fee $54.00+ Number of Employees @$17.00 each=$, �- <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed 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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,Ca#fornia Coe of Regulations. <br /> Applicant Name ,I Title ❑Partnership <br /> (Please PRINTor TYPE) h 1 ❑Corporation <br /> bj ,'Address 0A 2 - -x/ ��23T Phone(2L �f <br /> .Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type ChecklReceipt# Received By <br /> 12 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002992 PR0270100 F765 data Salinas <br /> Report#:7067.rpt <br />