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Applications WIII Be Proc. d When Submitted Properly Completed. Be Su, o Sign The Application. <br /> For Calendar Year <br /> Multiple Years (Permanent Housing Camps) <br /> Conditional Permit /� 7� OFFICE USE ONLY <br /> I.D. No. ;),F/ � /l� d (I, 1J] C <br /> Area <br /> Date Approved <br /> APPLICATION Permit <br /> (For Non-Transferable, Revocable, Suspendable) Date Mailed <br /> ENVIRONMENTAL HEALTH PERMIT New Existing <br /> TO OPERATE Change <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> FEE IS DUE WITH APPLICATION <br /> Location <br /> Jperator <br /> Address ___ Telephone No. <br /> Legal Owner New Owner Yes No <br /> Address Telephone No. <br /> No. Employees Housed Occupancy Dates From To 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. <br /> FEE SCHEDULE <br /> Permanent Camps Annual Permit $35.00 + No. Employees ® $12.00 each = S <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 ® $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 envelope together with applicable fee. DO NOT SEND CASH. <br /> Date_ Signed X Title <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ JUIy 1 8 Received sy July 31 <br /> BILLING REMITTANCE 6 REMIT <br /> BASE EXPLANATION DATE DATE REMITTEO AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receives by Data Receipt No. Permit No. Issua.Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TM ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95NI <br /> E1141250(11/88) <br />