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Applications Will Be Processed When Submitted Properly Completed. Be sure To Sign The Application. <br /> OFFICE USE ONLY <br /> For Calendar Year is,i F R1N �� Area <br /> Multiple Years(Permanent Housing Camps) <br /> Conditional Permit. Date Approved _ <br /> I.D. No.3y'7�-<' APPLICATION Permit---- <br /> (For <br /> ermit __(For Non-Transferable, Revocable, Suspendable) Date Mailed <br /> ENVIRONMENTAL HEALTH PERMIT New_ Existing <br /> TO OPERATEL ,- <br /> EMPLOYEE HOUSING OR LABOR CAMP v^ `dyjT — <br /> FEE IS DUE WITH APPLICATION <br /> Locationt ' 1990 <br /> Operator ChJVI <br /> Address .BOAC .3�� L < 'moi �� Telephone'Ntl; <br /> Legal Owner New Owner Yes No <br /> Address Telephone No. <br /> No. Employees Housed Occupancy Dates From To r Crop 42 UZ <br /> 1 <br /> From To Crop <br /> Total Number Days Used This Calendar Year <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 /> Permanent Camps Annual Permit $35.00 + No. Employees ® $12.00 each = $ — <br /> Orchard Camps $95.00 Transfer of Ownership$20.00 <br /> Amend Permit $20.00 + Additional Employees ® $12.00 each = E <br /> Late Application Penalty Fee $70.00 + _ Employees ® $24.00 each = E <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-addressed nvelope to Cher with applicable fee. DO NOT SE'sAA/SH. <br /> Dat a 3 �� Signed X �"• Title <br /> fes <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ ANNUALLY E) PER UNIT ❑ PER SITE 0 EACH ❑January 1 8 Receiveo By Janue 31 ❑July 1 6 Rec By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATIONBILLINGSDATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recelvel by Dale Recelpt No. Permit No. lesuance Dab Maiw DWK*Md <br /> APPLICANT—RETURN ALL COMES TO: ENVIRONMENTAL HEALTH PERMITISERVICES P O Box 2009 STOCKTON,CA SSIIe1 <br /> OFFICE ADDRESS <br /> 445 N.SAN JOAOUIN ST.,STOCKTON.CA EK0260111/BB) <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) '/ <br />