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o Applications Will a__ .ocessed When Submitted Properly Completed. e To Sign The Application. <br /> OFFICE USE ONLY <br /> For Calendar Year Area <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> Conditional Permit. Date Approved <br /> I.D. No. (For Non-Transferable, Revocable, Suspendable) <br /> Permit <br /> ENVIRONMENTAL HEALTH PERMIT <br /> TO OPERATE Date Mailed <br /> EMPLOYEE HOUSING OR LABOR CAMP New Existing <br /> FEE IS DUE WITH APPLICATION Change <br /> Location <br /> Operator <br /> Address Telephone�No. ��-���"' <br /> Legal Owner New Owner Yes No <br /> Address Telephone No. <br /> P y ,.�.-„...-��.. <br /> No. Em to ees Housed Occupancy Dates <br /> -- <br /> Crop <br /> From To Crop <br /> Total Number Days Used This Calendar Year <br /> Total Days Ocupied by 25 or more employees • <br /> (Camps Occupied by 25 or more employees for 6o or more days require <br /> a public water system permit*) <br /> Inactive_.— IMPORTANTIf this camp is net to be used this year but is_intended for,use in.the future, this application is to be <br /> returned.marked "Ina`c�e” 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 = $ <br /> Late Application Penalty Fee $70.00 + Employees a $24.00 each = $ <br /> I <br /> E 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, CCA. <br /> Please remit In the enclosed self-addressed envelope together with applicable fee. DO NOT SEND CASH. <br /> Date Signed X .Title. <br /> + Contact Environmental Health for information and application for <br /> a public crater system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January 1&Received By January 31 ❑July i &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE3 REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> ' Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES P O Box .2009 STOCKTON,CA 95201 <br /> OFFICE ADDRESS <br /> 445 N.SAN JOAOUIN ST.,STOCKTON.CA EH-0250(11/as) <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 468-3420 <br />