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Applications WIII Be Proc,.ased When Submitted Properly Completed. Be bu,., To Sign The Application. <br /> 3 /^ r q �/� OFFICE USE ONLY <br /> For Calender Year� , 1 oC Area <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> Conditional Permit Date Approved <br /> I.D. No. (For Non-Transferable, Revocable, Suspendable) <br /> Permit <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Date Mailed <br /> TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP New Existing <br /> FEE IS DUE WITH APPLICATION Change _ <br /> Location 19 U FE? t / LZ-0 C41 <br /> Operator JONi✓ A P<A 4- S f,-N J A/ <br /> Address /JiGlk 6, Cam STOl.0 ul-AJ Telephone No. 93/ (0 73O <br /> Legal Owner T6 Nv R A yfy New Owner Yes _fC- No <br /> Address A/1 f ✓ Telephone No. _ <br /> No. Employees Housed fU Occupancy Dales From f To Crop Ctle iC41,Ix r <br /> From Ta Crop <br /> Total Number Days Used This Calendar Year T/7 <br /> Total Days Ocupied by 25 or more 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 /> 5 <br /> Permanent Camps Annual Permit $35.00 + No. Employees -L 0 C $12.00 each = $ <br /> Orchard Camps$95.00 Transfer of Ownership $20.00 <br /> Amend Permit$20.00 + Additional Employees C $12.00 each = $ <br /> Late Application Penalty Fee $70.00 + Employees C $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-addresseVI (lope togetherrwith applicable fee. DO NOT SENDD CASH. <br /> Date Signed X l .� u !n � Title _ <br /> a and,Environmental Health for information aapplication for <br /> I public water system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January 1 &Rac WW By Jan31 ❑ Juy 1 6 R W By July 31 <br /> BILLING REMITTANCE i REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4 69 - <br /> R I M Dats Racaiq No. palma No. laauante Dale MeiNO Dalivele6 <br /> APPLICANT—RETURN ALL COMES TO: ENVIRONME TAL NEALTH PERMITISERVICES P O Som 2009 STOCKTON,CA 96201 <br /> OFFICE ADDRESS EHM50(Mee) <br /> 445 N.SAN JOAOUIN ST.,STOCKTON,CA <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 468-3420 <br />