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Applications Will Be Processed When Submitted Properly Completed. Be burs To Sign The Application. <br /> 1993OFFICE USE ONLY <br /> For Calendar Year Area _ <br /> Multiple Years(Permanent Housing Camps) APPLICATION Date Approved <br /> Conditionayl pppkermiit <br /> 1.D. No.�p)0 (For Non-Transferable, Revocable, Suspendable) <br /> Permit <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Date Mailed <br /> TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP New Existing <br /> Q.�Q p., !'� FEE IS DUE WITH APPLICATION Change <br /> Location CJ rCJC.J V�. 1•.� ICC X17TUJ� Cl�-• 9571f� <br /> OperatorILL EI t i LT S <br /> Address Gam• Z.O Telephone No. O <br /> Legal Own eh L I LJST� New Owner _Yes No p <br /> Address r 0 L reJ09 TCG K"1'�^� r G� 28I Telephone No 9� O o A.— <br /> No. Employees Housed _�p�Occupancy Dates From To �V Crop_ r { <br /> From To Crop <br /> Total Number Days Used This Calendar Year ,/.7� <br /> Total Days OCUPLad by 25 or more employees X7" — 5_0 <br /> (Camps Occupied by 25 or more employe.. for 60 or more days r;Quirs <br /> a public water system perms Y) <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 ' a <br /> Permanent Camps Annual Permit 535.00 + No. Employees S et) ® 512.00 each =/t - <br /> Orchard Camps $95.00 Transfer of Ownership $20.00 I`\� <br /> Amend Permit$20.00 + _ Additional Employees ® $12.00 each = S <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-addressed e v to ether wit applicabl fee. DO NOT SEND CASH. ._.,, 1 <br /> Date 2 Signed —fitte 0SMJ t175IV`Y's✓T1 �= <br /> • Contact Environmental a.. th for nformation it application for <br /> a public water system peas L• <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January t a Received By January 31 ❑ July 1 6 RaceNed By July 31 <br /> BILLING REMITTANCE f REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> "t tZ07/ <br /> Ived by ale Receipt No. Permit No. Issuance Dau Maud Delnered <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMITISERVICES P 0 bolt 2009 STOCKTON.CA It <br /> OFFICE ADOREBa EM-02501111Ba) <br /> 445 N.SAN JOAOUIN ST.,STOCKTON,CA <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 468-3420 <br />