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Applications Will Be Processed When Submitted Properly Completed. Be qc ree To Sign The Application. For Calendar Year y \ Multiple Years (Permanent Housing Camps) Conditional Permit OFFICE USE ONLY I.D. No. 39�9 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 ��L..Op1�' ,r FEE IS DUE WITH APPLICATION Cr ,Location.�L ' 7b K1 ^1 I �f1 Q. 1\ter► i�Gi/j l[YYI Cr Operator f o60-il tCS @�I Address `ci -"/ is-- Telephone No. 444 67F3 Legal Owner 1?.'6 ' hT C f ct. CL S 5 a +'+ New Owner—Yes No i- Address �5 4 Telephone No. No. Employees Housed 1 g Occupancy Date From � To • ^+(Cropp 426P COMMUNITY FACILITIES Men: No. of Toilets No.of Showers 2, No. of Lavatories 'Z-- Women: No. of Toilets No. of Showers_ _ No. of Lavatories Community Kitchen: Yes =rilo HOUSING FACILITIES Dormitories No. i Family Units No. A. Housing capacity (Building or other housing accomodations, excluding recreational vehicles or mobilehomes) B. Number of employees housed in recreational vehicles or mobilehomes being provided by employer Z C. Number of spaces being provided for mobilehomes or recreational vehicles which are owned by employees No. Employees Total of Lines A I B + C ...................................................................................... z--'f'! Permanent Camps Temporary(Orchard) Camps ❑ Annual Permit$25. No. Employees- _ @$3 ea.= Sh.OU ❑ ❑ Annual Permit, Providing Water$70 Transfer of ownership $8.00 ❑ Site- R.V. or M.H. Parking $6 ea._ ❑ 13 Annual Permit,Water Not Provided$60 Application to Increase Employee No. $8 No.Additional Employees$3 ea. TOTAL FEE ENCLOSED ---- AD pi i ca n I ---Applicant agrees to all necessary inspections incident to issuance of a permit to operate.Applicant agrees that this project shat I be operated and meintai ned in accordance with the applicable provisions of Chapter 4,Part 9,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 addressed envelope together with applicable fee. DO NOT SEND CASH. 7 Date Signed X Title 0V N4 FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceNed By January 31 ❑ July 1 8 Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE y _93 LESS 1' i PRORATION PLUS PENALTY OTHER OTHER Received by Dale Receipt No Permit No Issuance Dare Malleo Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201