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Applications Will Be Processed When Submitted Properly Completed. Se Sure To Sign The Application. <br /> GOFFICE USE <br /> For Calendar Year 1 1— Area <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> Conditiopl_grlm�ity�-�1�_ Dale Approved <br /> I.D. No.=t ✓7 (For Non-Transferable, Revocable, Suspendeble) <br /> 99 ENVIRONMENTAL HEALTH PERMIT Permit <br /> F/p "00a94(p TO OPERATE Date Mailed <br /> EMPLOYEE HOUSING OR LABOR CAMP New_ Existing <br /> /�� FEE IS DUE WITH APPLICATION Change <br /> Location aACe),J L9LJawrp C6al..iD 3 - (--(A 1� C^Lkp <br /> Operator S <br /> Address- 42✓ --taC 'T 04 tS k'( Telephone No. -7 7 1 <br /> Legal Owner PL14n '�� � <br /> New Owner_ Yes No <br /> Address b(G!/IZ /71`-P,003LC) L)I/D .-rF /LV ,�I�t�I7r 16 A Telephone No. G3r'c)1It, <br /> No. Employees Housed -,T-1 Occupancy Dates From ..IA/-J To �- Crop Roet) <br /> From To Crop <br /> Total Number Days Used This Calendar Year -;?c <br /> Total Days Ocupled by 25 or more employees <br /> (Camps Occupied by 27 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 /> C Permanent Camps Annual Permit $35.00 + No. Employees -51 ® $72.00 each m S 6 I <br /> Orchard Camps $95.00 Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + Additional Employees 4D $12.00 each = S PAYMENT <br /> Lets Application Penalty Fee $70.00 + Employees ® $24.00 each m S 7 <br /> FLU ! 0 19 <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 wish the Applicable Ixovisl0nsi){�liob Ea10bY0111fJTY <br /> Housing Act, Chapter 1, Pan 1, Division 13 of the Health and Safety Code and Chapter 1, Subchap'("""251-CQNVICES <br /> r-NVIRONMENTAL HEALTH DIVISION <br /> Please remit In the enclosed self-addressed�nlTtog tier wi apph I-Ie lee, DO NOT SEND CASH. <br /> Date Signed X Title 4�64-C. rfvL�1 E7F �. <br /> • Contact Qlvlrenmental Realtb for intonation -4application for <br /> a public water system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ ANNUALLY 17 PER UNIT 0 PER SITE O EACH ❑ Janus 1 A A"., a Jenue Jt ❑ Jui,16 R..e By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PEN TY <br /> OTHER <br /> OTHER <br /> 1��tun al(o/a� <br /> Recen'W OY De1e : NO31amNO Date MelbDNMM <br /> APPLICANT—RI TURN ALL COMES TO. ENVIRONMENTAL HEALTH PERMITMERVICES Post Off It Box 388 Stockton, CA 95201-0388 <br /> Office Addresses EN 0260(Itme) <br /> 304 E. Weber Avenue, Third Floor <br /> Stockton, CA 95201 Phone (209) 468-3420 / PHS 179 (4/96) <br /> (No mail is received at this address) <br />