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Applications WIII ge Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> For Calendar Year <br /> Multiple Years(Permanent Housing Camps) <br /> Conditional Permit <br /> I.D. No. / —7 j?r�p) € OFFICE USE ONLY <br /> Area <br /> APPLICATION Date Approved <br /> Permit <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT Date Mailed <br /> New Existing <br /> TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP Change <br /> FEE IS DUE WITH APPLICATION <br /> location <br /> ( h Jperator <br /> Address <br /> Legal Owner Telephone No. <br /> Address <br /> New Owner Yes No <br /> No. Employees HousedTelephone No. <br /> Occupancy pates From To <br /> Crop <br /> From To Crop <br /> Total Number Days Used This Calendar Year <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. i <br /> FEE SCHEDULE <br /> Permanent Camps Annual Permit$35.00 + No. Employees @ $12.00 each = $ <br /> Orchard Camps$85.00 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 /> Applicant agrees to all necessary inspections incident to issuance of permit to operate. <br /> 111 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 f, Subchapter 3, Title 25, CCR. <br /> Please remit in the enclosed self-addressed envelope together with applicable fee. DO NOT SEND CASH. <br /> Dale Signed X <br />... Title <br /> FOR DEPARTMENT USE ONLY <br /> Fees is Due. ❑ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jan ue ry 31 'JuIv 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ 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 />- Received py Date Receipt NO. Permit No. Issuance Data <br /> Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMITISERVICES 1601 HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 96201 <br /> EH-0250(11/88) <br />