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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> For Calendar Year OFFICE USE ONLY <br /> Multiple Years (Permanent Housing Camps) Area <br /> Conditional Permit APPLICATION <br /> Date Approved <br /> I.D. No. (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT Permit <br /> TO OPERATE Date Mailed <br /> EMPLOYEE HOUSING OR LABOR CAMP New Existing <br /> FEE IS DUE WITH APPLICATION Change <br /> Location <br /> Operator — <br /> Address <br /> Telephone No. <br /> Legal Owner New Owner_ Yes _ No <br /> Address <br /> No. Employees Housed Occupancy Dates Telephone No. <br /> From To Crop <br /> From _ To Crop <br /> Total Number Days Used This Calendar Year <br /> Total Days Ocupled by 25 or mora employees <br /> (Camps Occupied by 25 or more employees for 60 or more days require <br /> a public water system Permit.; <br /> Inactive — IMPORTANT. If this camp is not to be used this year but is intended for use in the future, this application is to be <br /> returned marked "Inactive" too protect your land use status. <br /> FEE SCHEDULE <br /> Permanent Camps Annual Permit $35.00 + No. Employees @ $12.00 each = S <br /> Orchard Camps$95.00 Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + _ _ Additional Employees @ $12.00 each = <br /> — Late Late Application Penalty Fee $70.00 + _ Employees @ $24.00 each = $ <br /> Applicant agrees to all necessary inspections incident to issuance of permit to operate. <br /> Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Employee <br /> Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. <br /> Please remit in the enclosed self-addressed envelope together with applicable fee. DO NOT SEND CASH. <br /> Date Signed X Title <br /> • Contact IItvironmental Health for information and application for <br /> a public water system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑July 1 8 Recelvad By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE f REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dala Receipt No. Permit N. Iseuence Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO'. ENVIRONMENTAL HEALTH PERMIT/SERVICES P O Box 2009 STOCKTON.CA 95201 <br /> OFFICE ADDRESS <br /> 445 N.SAN JOAQUIN ST.,STOCKTON,CA EH-02541(11/e0) <br /> (NO MAIL IS RECEIVED AT THIS ADORESSI Phone (209) 468-3420 <br />