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Applications Will Be Prc Vhen Submitted Properly Completed. Be Su. In The Application. For Calendar Year �Wtl Multiple Years (Permanent Housing Camps) OFFICE USE ONLY Conditional Permit A - _.. I.D. No. � Areall C _ 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 . ��C'-Ci"tL+'x'e-'*' CA-0-A Operator tiru4210 AddressV�OX� 543 7A `I v zi / - - Telephone No. Legal Owner ) , . _ �V„[�_ _ New Owner Yes No X. Andress ,J - Telephone NO. -- No No. Employees Housed 4 Occupancy Date From -.{AVrJ To v6n. Crop leA) - COMMUNITY FACILITIES Men: No. of Toilets 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. 3 A. Housing capacity (Building or other housing accomociations, excluding recreational vehicles or mobilehomes) B. Number of employees housed in recreational vehicles or mobilehomes being provided by employer C. Number of spaces being provided for mobilehomes or recreational vehicles which are owned by employees _ No. Employees 'f Totalof Lines A + B +C ......................................................................................_ PERMANENT CAMPS ANNUAL PERMIT $35.00 NO. EMPLOYEES _ f$12.00 each = ORCHARD CAMPS $90.00 TRANSFER OF OWNERSHIP $20.00 AMENDED PERMIT $20.00 ADDITIONAL EMPLOYEES $12.00 each TOTAL FEE ENCLOSED 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 the Employee Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CAC. Please remit in the enclosed self addres envelope toget r ith applicable fee. DO NOT SEND CASH. Date t Signed X _%�Title _—?Ole �" FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ ER SITE ❑ EACH ❑ January 1&Received By January JI ❑ July 1 &Received By July JI REMIT BILLING REMITTANCE S BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,PO.Box 20M STOCKTON,CA IS201 ® EH-02501121841