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Applications WIII Be Pro( 1 When Submitted Properly Completed. Be St Sign The Application. f For Calendar Year Multiple Years(Permanent Housing Camps) Conditional Permit OFFICE USE ONLY I.D. No._� - Area Date Approved APPLICATION Permit (For Non-Transferable. Revocable. Suspendable) Date Mailed ENVIRONMENTAL HEALTH PERMIT New Existing TO OPERATE Change EMPLOYEE HOUSING OR LABOR CAMP FEE IS DUE WITH APPLICATION Location Operator Address -� _ Telephone No. Legal Owner New Owner Yes _7)�__ No Address Telephone No. No. Employees Housed Occupancy Dates From 1 f To PEET Crop From To Crop Total Number Days Used This Calendar Year _ 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 returned marked "Inactive" too protect your land use status. FEE SCHEDULE Permanent Camps Annual Permit$35.00 + No. Employees ® $12.00 each = $ Orchard Camps$95.00 Transfer of Ownership$20.00 Amend Permit$20.00 + Additional Employees ® $12.00 each = $ Late Application Penalty Fee$70.00 + Employees ® $24.00 each = $ Applicant agrees to all necessary Inspections Incident to Issuance of permit to operate. Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Employee Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. Please rami in the enclosed self-add aspect envelop f ether with applicable fee. DO NOT SEND CAS((//{${$��'' Dare Z I DSigned X Title r FOR DEPARTMENT USE ONLY Fees is Due: ❑ANNUALLY ❑ PER UNIT L PER SITE ❑ EACH I_ January 1 8 ReceNeE By January,31 ❑July 1 3 Received!By July 31 BILLING REMITTANCE S REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION _ PLUS PENALTY OTHER OTHER Received by Date Recin,l No Permit No. Issuance Date Mailed Delwow APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 HAZELTON AVE.,P.O.BOX 2(09 STOCKTON,CA 96201 EH0 01/Be)