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_.' Applications Will Be P ased When Submitted Properly Completed Be S to Sign The Apollcatlon, <br /> OFFICE USE ONLY, t <br /> k. <br /> For Calendar Year, Area <br /> w . <br /> Multiple Years(Permanent Housing Camps) " �x APPLtCAT'ON , ° -�� -, Date Approved. .. <br /> Conditional Permit, <br /> 3., �` <br /> I.D. No.- (For Norwtransfereble, pevocablb; Sulipshdable) .. Permit <br /> X` ENVIRONMENTAL HEALTH PERMITS Date Mailed <br /> ?' "STO OPERATE <br /> New.. Existing <br /> EMPLOYEE HOUSING OR LA13OR CAMP <br /> Change <br /> FEE IS DUE WITH AP <br /> PLiCAT10N <br /> Lection - <br /> Operatoi 7. <br /> Address OTelephowne No. <br /> r <br /> New. ner LiL­866 p bio v <br /> Legal Owner <br /> Address nY. s t':-���_...;. - <br /> No. Employees Housed Occupancy Dates From To Crop <br /> From To Crop <br /> of <br /> J <br /> t Pitarttbbr 178yt9 tA ;3rtfis IridarYiy ) <br /> Totlal`Days Ocupied by 23 or more employirs <br /> (Camps Oceupied by 23.ox more emplcyeas for boor more days require <br /> a public rater system permits) <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..: G-T 1v <br /> FEE SCHEDULE .?. <br /> Permanent Camps Annual Permit$95:004+ No Employees ., $12.00 each >= 5 = <br /> 1 Orchard Camps$95.00 rransiet of Ownership$20.00 "V <br /> Amend Permit $90.00 . + Addltlbnel Employees $72.00 each <br /> _ Late Application Penalty Fee$70.00 + Employees a $24.00 each = 5 fn( <br /> Applicant agrees to all necessary inspoctions incident to ISSuance of permit to operate <br /> Appiicant agrees that this pnl)ect'shall be operated and rttaintained In accordance with the Applicable provisions of the Employee s fi <br /> CNN IV <br /> Housing Act, Chapter 1, Part 1,Division 13 of the Heait d Safety Code and Chapter.1 Subchapter 9,Title 25, CCR, <br /> Please remit in the enclosed self-addressed a togeth tie: Do NOT SEND CASH. <br /> _r itle Secretat y/Treasurer <br /> Signail' ' <br /> Date t Saral ax , <br /> Conti t'tr►vl'sonantal lies ;Co ri o nape �siftti8 lor .... <br /> a public Yater fYftBO Perm t. x xa;.y „. rj <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: D ANNUALLY ©PER.UNIT „ ©PER$ITE ©t Ar Ff i]°Janu>f 1 A PAdsived Jams 31 ❑J 1 A Ralik"B J 31 <br /> REMIT <br /> 91LLINp 'p REAArTTAN�@ i AMOUNT 611E CHECKED <br /> BASE EXPLANATM DATE � ::�' WATE-.r REMITTEb r. AMOUNT <br /> � k <br /> FEE <br /> LESS <br /> PRORATION <br /> "b <br /> x <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Reosh,sd by Date Recelo N6. -Psmtit No. Isiiusnte Dab.fi MRINd Deftomd <br /> APPLICANT F9 FIN ALL GI]PIEB TO: ENVIRONWNTAL HEALTH PEgMIT/8Eg1iICE8. + .F O Bait 2009 h7odicTDN,CA 68201 <br /> EH-0OM(1 1188) <br /> Or'I�ICf ADDRESS, i . . <br /> 445 N,SAN JOAOUINST.,STOCKTON,CA Phone 420 <br /> (NO MAIL IS RECEIVED AT THIS ph <br /> S AODAESS) (20. 9)--..468c3. <br /> i <br />