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f0Ai4( IN c'01�: [ a Pt.OLIC HEALrw~RVICI-' PAYWNT" <br /> :V Vlk0 Nbl f"Ei-Al, H.RALTtl DI ION `=P�:,C <br /> 304 P. WEBER AVENUE a THIRD FLOOR a SIOQEToN, CA 9� <br /> 269.2466-3429 DEC 2 41997 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PIISUC HAOUIN qf;A 7, <br /> ENVIRONMENTAL HEALTH, ION <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> .-No%Camp :C'oatduano)Permh a AAAMAl Pas toh f or f.aleudu low: <br /> Amended Pannus mah/plo leas'(Petmsnwt flowing saps an*) ,Date Apprat'ed <br /> c how of Owater _Cheap of Owner Yma MAded: _- <br /> _Chspee of 04mtwtwt'.Lddroa _Chastge of[Amer Addr"s y.t�t p <br /> AddtAnet limptoyew <br /> Plsem Note m v C:oonw. loos or Oss"r,In FveaWOprrgf 0"er to/broadlw dttt city on this farm <br /> 51le Nance: PACON ISLAND CrL19Y F'3 Lxatfun land 1F BACON!SL.-ND RD I"nu NW MIDDLE RI',FR <br /> Operator: KYSER FAWNIS S'frX_KR)N <br /> Melling Address" PO BOX 343. 5TCx'KTOJ rA 95201 Fadt1W Phone N: 2(t9-46A-797v <br /> Legiii Owner, DELT AWEILr.Nb3 - Nowuwm ar 11 yw i Nn <br /> Owner Addrees. roll" %ITDIABLOBLND#320.LAFAi'ETTE CA 94539 Owner Phone N: SiD-w43-.^2e <br /> a owmumty'€wtiilties Proykied by Camp. commnaay Klichemt Ditto a No 17 <br /> Mess. Numbst of Tdtmu_f 0 Number ofSbow---5_ Nnmbv of Lanaorlos ( _ <br /> WomenNumberct'Tolirtt-3 Number of Show—..? Number of Lovwtortet _y_ <br /> Housing Aszonamillotlous to be Utilized dih Year. <br /> Dulldinal Emoloyto tawlol e <br /> Daunt&im: _ 5 1 Owna•Owtwd NIRRN' <br /> si UW <br /> waalq _t2U Owmr Owmed Ric Cats -- <br /> ApaOeema _ 'NIRRV spec" _ <br /> To fm;of BothColAlfmys <br /> OLrupency Dotes: _ <br /> Mm / l F-1-9S to N 13 1 /v t Crop '-C 60 YKW Nombar of Dqe to be mod thio Colons"year <br /> hnm "t 1 to I stal Dry "s Otcapbvd by or mwv Employel_ 6L1J <br /> - - - -- P — 1(4e: ,Wr.::V:.14"-nv.3 or rre rrystoyer:;..., iN or tare dq'r aYMr <br /> riyr.;re.r Pahtlr JI.WrSya4w Pomp <br /> Inactive rstpmWm': M n,afar to 0mrecf vain lend w .earur.,�c2�writ mor br uvd lh:;,•.na.?,u Is 4WMA dfW as,rA Lee"Ihlarr CTtrea rk;r A,t :n •,: . <br /> lair <br /> ee schedw — <br /> 1 <br /> Permanent Camp Annual Penile Siam+- Namr e of Fmoe <br /> ploys S 'R'812.01)ouch—S_, E yy C(-; <br /> � <br /> :_- Orchard Camp Permit Fee=$95.00 5_ <br /> Q Trander of Ownershlp=820.00 8 7 <br /> Pel-0111 Anlendmeut=S20.00* Numbor at Additlend Employe"___.d$12.00 each= _ <br /> 1 _] Late Application Fee 8'0.004 Number ofFmptoyees— _ .'a824.00 each=3_— —_ <br /> I <br /> I Fee moat be submitted with Application TOTAI,FVF DUE: 6 dAj7_2p _ <br /> f?EAltr'1'OT.1l,FFLl5CALCr7.AIYD.IBOVELNTIIY.PNCYO.4COsesf-addre4sedP.IV\'PLOPE. .IitEPC77PCXSi�e.Y1Bt1'1Y?: PH.SJDHD 1 <br /> 1 _I <br /> Applicant&gifts to all necessary inspections incident to issuance of a k4MNTI To OPKRATE. Applicant agrees that till.project(comp)shall be <br /> operwted and makitalned In wccotdance with the applicable provbJon4 of the Esmlay19 novsuw Acr,Chapter 1,Pan t.Dfeidon)&of the Haaldt <br /> and.Sa .v Cade and c.'hapter I.subehapter s, Title m Cao rola can ofBeRwladem. /K,✓A' 0'1'4-7q tj <br /> Applicant Noute(pieaeeprbu or"e)_M r-Zc-- C'A wt �t7(a1,lr 7'1 CyGN c..ta�. 1�-f Far-n c`1 EL_ <br /> Appllcaut Signature —Tr'( l� _ Dute of Applicition_ _/=�q I <br /> Fw Amtont Anwxtt Pald 1 hate of i i psYarnt lVDe i_rGhwoWReoelpte ill Awottleed By _ <br /> Emfsoyss a. 0826I ACG Of 0002506 Fac 10. 002946 I PR S. 270099 — __PWS d1C -—•_— RIE; 275% — . <br />