BILLING - Laserfiche WebLink

Home Browse Search

Applications Will Be Procc.;sed When Submitted Properly Completed. Be Sure,`To Sign The Application. LABOR CP.� For Calendar Year L P,kA : I--- Multiple Multiple Years (Permanent Housing Camps) OFFICE USE ONLY Conditional Permit I.D. No. 39-2l Area _ APPLICATION Date Approved (For Non-Transferable. Revocable. Suspendable) Permit ENVIRONMENTAL HEALTH PERMIT Date Mailed TO OPERATE New_Existing EMPLOYEE HOUSING OR LABOR CAMP Change FEE IS DUE WITH APPLICATION Location /`9��bf6 Operator q[ FLT ��Qu SSE'M Address 'Sa titins Q. Telephone No. -14-1 61P3 Legal Owner New Owner—Yes No Address _ - Teleepph`o�ne No. No. Employees Housed J� Occupancy Date From f To r.�-1_1 Crop 67-A,4? COMMUNITY FACILITIES Men: No. of Toilets v No.of Showers No. of Lavatories Women: No. of Toilets_ No. of Showers No. of Lavatories Community Kitchen: _Yes —No HOUSING FACILITIES Dormitories No. Family Units No. A. Housing capacity (Building or other housing accomodations, excluding recreational vehicles or mobilehomes) 2 `� B. Number of employees housed in recreational vehicles or mobilehomes being provided by employer 2- C. C. Number of spaces being provided for mobilehomes or recreational vehicles which are owned by employees No. Employees Totalof Lines A+ B + C ...........................................................................I....I..... 2 L Permanent Camps Temporary (Orchard) Camps ❑ Annual Permit$25. No. Employees ii ❑_ $3 ea.- :R/ o� Annual Permit, Providing Water$70 ❑ Transfer of ownership $8.0(y0 Site- R.V. or M.H. Parking $6 ea. ❑ Annual Permit,Water Not Provided $60 ❑ Application to Increase Employee No. $8 No. Additional Employees$3 as. — OU TOTAL FEE ENCLOSED 9( Applicant agrees to all necessary inspections Incident to issuance of a permit to operate.Applicant agrees that this project shall be operated and maintained in accordance with the applicable provisions of Chapter 4,Pang.Division 2 of the Labor Code and Title 15,California Administrative Code,Chapter 2.Applicant agrees that he or his agent will accept service or any legal notice or process, at his address of record. Please remit in the enclosed self addreeer ve pe gather with applicable fee. DO NOT SEND CASH. Date Signed XJ%% Title 0 40W C V FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 11 July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 00 I �iSS o LESS PRORATION PLUS PENALTY ty OTHER OTHER Cj-- 2-A, tcS Received by Date Receipt Na. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201