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Applications Will Be yed When Submitted Properly Completed. Be Sign The Application. For Calendar Year�6 T l Multiple Years (Permanent Housing Camps) Conditional Prm' OFFICE USE ONLY I.D. No. �7^ APPLICATION Dae Appr ed (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 16500 W. Clifton Court Road Stockton, Ca. Operator COl]171r z Farms ---- Address P.--a.-Box_6_Q66Stockton, Ca. 95206Telephone No. 209) 943-2079 Legal Owner Sarale Farms New Owner Yes � No X Address 16500 W. Clifton Court Rd Stockton Ca. 95206 - T e ho S `_ No. Employees Housed 25 Occupancy Date From F _To� �b�g Crop arS guS COMMUNITY FACILITIES Men: No. of Toilets No. of Showers No. of Lavatories _ Women: No. of Toilets --- No. of Showers 'y No. of Lavatories Community Kitchen: �/_ Yes — No HOUSING FACILITIES Dormitories No. Family Units No. N/A A. Housing capacity (Building or other housing accomodations, excluding recreational vehicles or mobilehomes) NO B. Number of employees housed in recreational vehicles or mobilehomes being provided by employer None C. Number of spaces being provided.for mobilehomes or recreational vehicles which are owned by employees_No _ ~ Tota!of Lines A +B + CNo ..........•......................` .. ....... ; Employees 25 f PERMANENT CAMPS (INCLUDING ORCHARD CAMPS) YK/ Annual Permit $35. No. Employees 25 @ $12. each 300.00 Transfer of Dwnership $20. Amended Permit $20. Additional Employees $12. each ; TOTAL FEE ENCLOSED 335.00 Applicant agrees to all necessary inspections incident to issuance of a permit to operate. Pl SD Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Q�C, 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 dr noel a to he h applicable tee. DO NOT SEND CASH. NMN'(P�1C�S Date L 03/01/88 Signed Title President v�RO 5�R FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By Januar _ Y 31 ❑ July 1 &Received By July 31 i BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED I FEE AMOUNT LESS PRORATION PLUS j PENALTY � OTHER OTHER R - ed by Date Receipt No. Permit No. Issuance Date Mailed Delivered PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.BOK 2009 STOCK70N,CA 95201 ® EH-0250 412/641