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Applications Will Be Pn" :d When Submitted Properly Completed. Be r t Sign The Application. <br /> For Calendar Year <br /> Multiple Years(Permanent Housing Camps) <br /> Conditional Permit OFFICE USE ONLY <br /> I.D. No. <br /> Area <br /> Date Approved <br /> APPLICATION Permit <br /> (For Non-Transferable, Revocable, Suspendable) Date Mailed <br /> ENVIRONMENTAL HEALTH PERMIT New Existing <br /> TO OPERATE <br /> Change <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> FEE IS DUE WITH APPLICATION <br /> Location d <br /> Operator <br /> Address Telephone No. Oki --764-74 <br /> Legal Owner New Owner Yes No <br /> Address Telephone No. <br /> No. Employees Housed Occupancy Dates From To Crop r <br /> From To Crop <br /> Total Number Days Used This Calendar Year — 360 <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 is $ <br /> Late Application Penalty Fee$70.00 + Employees ® $24.00 each = $ <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-addre a envel pet lher with ap licable fee. DO NOT SEND SH. <br /> 1 <br /> Date Signed X Vv �- Title <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 6 Recelved By January 31 ❑July 1 S ReceNed By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recelved by Data Receipt No. Permit No. Issuance net. Mailed D.[,..d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/ RVICES 1601 HAMILTON AVE.,P.O.BOX 1,049 STOCKTON.CA 95201 <br /> E1141250 Il 1188) <br />