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Applications Will Be Pi---seed When Submitted Properly Completed. Be --.e TO Sign The Application. t� <br /> Flo )e`2 a Fz 3 OFFICE USE ONLY <br /> o <br /> For Calendar Year 1995 �/� Area <br /> Multiple Years(Permanent Housing Camps) APPLICATION <br /> Conditional <br /> �Permit l Date Approved <br /> I.D. No 3 31 I0 (For Non-Transferable, Revocable, Suspendable) <br /> Permit <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Date Mailed <br /> TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP New Existing <br /> FEE IS DUE WITH APPLICATION Change <br /> Location CP 21 Henning Tract McDonald Island <br /> Operator Roscoe Zuckerman <br /> Address P.O. Box 487 Telephone No. 209-469-7979 <br /> Legal Owner Zuckerman Mandeville New Owner Yes x No <br /> Address P.O. Box 487, Stockton, Ca 95201 Telephone No. 209-469-7979 <br /> No. Employees Housed 82 Occupancy Dates 1 /1 /95 From 1 /1 /95 To—' /1 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 60 or more days require <br /> a public water system permit*) <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 /> _ I Permanent Camps Annual Permit $35.00 + No. Employees 1 02 a $12.00 each = $ 1224.00 <br /> Orchard Camps$95.00 Transfer of Ownership $20.00 " <br /> Amend Permit $20.00 + Additional Employees 4 $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 /> n <br /> Please remit in the enclosed self-addre �I pe appiic a fee. DO NOT SEND CASH. <br /> Vick <br /> Date 1 /1 /95 <br /> Signed X I � Title President <br /> * Contact Environmental Health for information and application for <br /> a public water system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July I31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Weivdd 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 EH-0250(11/88) <br /> 445 N.SAN JOAOUIN ST..STOCKTON,CA <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 463-3420 <br />