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San Joaquin County-Environmental Health Department 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP n n/' ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) fitAnnual Permit for Calendar Year 2o2 4 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID N: 0002983 *Additional Employees State ID#: 39-0100-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000100 Site Name: CCRC FARMS LLC 39-100 Location: 20750 W MANDEVILLE LEVEE RD,STOCKTO Operator: CCRC FARMS LLC Mailing Address: PO BOX 248, HOLT CA 95234 Facility Phone#:(209)464-2959 Legal Owner: CCRC FARMS LLC New Owner? ❑Yes ❑ No Ov,net-Address: PO BOX 248, HOLT CA 95234 Owner Phone#:(209)464-2959 Community Facilities Provided by Camp Community Kitchen? ❑ Yes �y�p�L No ,J,w��,9p 1 Men: Number of Toilets !L Number of Showers is" 3rgV"v"^ Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories / j from 01 l 01/Q4 to/6L /_IL/_a_4__ Crop SF Dwellings from _/_/ to / / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: ,& MH/RV Spaces Note rAYMENT TOTALS Camps occupied by 25 or more Employees for 60 or more days in EIVED Require a PUBLIC WATER SYSTEM Permit V I_— ❑Inactive DEC 1 9 2023 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."AN JO Fee Schedule AQUIN COUNTY IRONMENTAL Permanent Camp Annual Permit Fee $50.00+ Number of Employees `J @$17.00 each=$ TMENT ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ DU Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD .Applicant agrees to all necessary inspections incident to issuance of a PERMIT 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 California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations.Applicant Name rzXf /ir' Title &rL(il/h �/(Q�q�t/ ❑ Partnership (Please PRINT or TYPE) //// Corporation Address p �,aX (��'� S2��j Phone 6cl6�• �� Applicant Signature Date of Application 2 Amount Paid ate of P ment Payment Type Check/Receipt# Received By Account ID 55'5— - — L),y Z /C I f � 0002554 Facility ID Program Record ID ! O P/E / Assigned to PWS ID FA0002992 PR0270100 2765 9834-SUSZYCKI WA0515717 Report#:7066 Application Printed:11/1/2023