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Applications Will Be Pr led When Submitted Property Completed, Be Su o Sign The Application. <br /> For Calendar Year _ ^��CIL_FN <br /> SSE <br /> Multiple Years (Permanent Housing Camps) OFFICE USE ONLY <br /> Conditional Permit <br /> I.D. No. 3pq Area <br /> APPLICATION Date Approved-- <br /> (For <br /> pproved_(For Non-Transferable. Revocable,Suspendable) Permit <br /> ENVIRONMENTAL HEALTH PERMIT Date Mailed <br /> TO OPERATE New_ -Existing <br /> EMPLOYEE HOUSING OR LABOR CAMP Change <br /> FEE IS DUE WITH APPLICATION <br /> Location _'J�y6 _ ��n l�ltit /- V� �1•�l C.Q� /✓g1C_o_ <br /> Operator _ 0 6 QHS <br /> Address _S2rn Q-_ __ _ _ _ Telephone No. <br /> Legal Owner .Sa"yri e—_ _ _ _ _ _ _ _-- New Owner — Yes No <br /> Address _ �S_2."++9. q - -- Telephone No. <br /> No. Employees Housed _/Jr _ Occupancy Dale From -3//— To —AV-1 — Crop 67-,l _ <br /> COMMUNITY FACILITIES <br /> Men: No. of Toilets No.of Showers L No. of Lavatories Z— <br /> Women: No.of Toilets No.of Showers No. of Lavatories <br /> Community Kitchen: rYes _ No <br /> HOUSING FACILITIES Dormitories No. Family Units No. _ <br /> A. Housing capacity (Building or other housing accomodations, excluding recreational vehicles or mobilehomes) <br /> B. Number of employees housed in recreational vehicles or mobilehomes being provided by employer <br /> C. Number of spaces being provided for mobilehomes or recreational vehicles which are owned by employees <br /> No. Employees <br /> Totalof Lines A - B . C .................................................................................. <br /> PERMANENT CAMPS (INCLUDING ORCHARD CAMPS) <br /> Annual Permit $35. No. Employees /S @ $12. each = !8()UJ <br /> Transfer of Ownership $20. <br /> Amended Permit $20. Additional Employees $12. each <br /> TOTAL FEE ENCLOSED <br /> Applicant agrees to all necessary inspections incident to issuance of a permit to operate. <br /> Applicant agrees that this project shall be operated and maintained in accordance with the Appticable provisions of the <br /> Employee Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title <br /> 25, CAC. <br /> Please remit in the enclosed self addressed envelope together with applicable fee. DO NOT SEND CASH. <br /> Date �4L_ LI lsrSlgned X �t-t-�� Title vim"�Fr­ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Recerved By January 31 ❑ July 1&Received By July 31 <br /> BILLING REMITTANCE 5 REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE •QO +—\Ob <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER OD - — — <br /> OTHER <br /> Recervad by Dare Receipt No Permit No. Issuance Date Me11e0 Dallver¢d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.NA LTON AVE.,P.O.Soa 1009 STOCKTON,CA 98201 <br /> S EH-02W 112/841 <br />