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aL Applications Will Be Processed When Submitted Pr r L pp t d Properly Completed. Be S ppllcation. OFFICE USE ONLY For Calendar Year rea _ Multiple Years (Permanent Housing Camps) APPLICATION Condition r It ate Approved I.D. No.. 40 (For Non-Transferable, Revocable, Suspendable) ermit f-' P 't-00a�'"05 ENVIRONMENTAL HEALTH PERMIT ate Mailed '�✓ �JSa�� TO OPERATE OO EMPLOYEE HOUSING OR LABOR CAMP jA Existing I FEE IS DUE WITH APPLICATION range Location -� �a• Operator L+j Address �c L CsI 4 t/rd. C c:T" ��@[J t'�U, C.A- °�Yy cy '� Telephone i.2. - Legal Owner �� It 91,6 �Yec New Own No Address Telephone No. Employees Housed Occupancy Dates From To _ Crop From To Crop Total Number Days Used This t�y Total Days Ocupied by 25 as (Camps Occupied by 25 or a )r 60 or more days require a public water system perm Inactive — IMPORTANT. If this camp is not to be used this year but is intended for us this application is to be returned marked "Inactive" too protect your land use status. FEE SCHEDULE 91 Permanent Camps Annual Permit $35.00 + No. Employees ® $12 Orchard Camps $95.00 Transfer of Ownership $20.0 Amend Permit $20.00 + Additional Employees 0 $12. Late Application Penalty Fee $70.00 + Employees ® $24. Applicant agrees to all necessary inspections incident to issuance of permit to operate. Applicant agrees that this project shall be operated and maintained in accordance with the Appli to Employee Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, ie 25, CCR. Please�remi�aC�t in the enclosed self-addressed a elope gether with applicable fee. DO NO Date_ 1 / 2Signed X / Title • Contact LInvironmental Realth for information and application for a public water system permit. FOR DEPARTMENT USE ONLY Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January 1 E Received By ily 1 6 Received By July 31 BILLING REMITTANCE $ REMIT EASE EXPLANATION DATE DATE REMITTED CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Lb 31091 Cl*4L)9S5 - 11-77 Received by Date Receipt No, Permit No Issuance Date Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Post Office Ba CA 95201-0388 Office Address 304 E. Weber Avenue, Third Floor EH-0250(11/88) Stockton, CA 95201 Phone (209) 468-3420 PHS179 (4/96) (No mail is received at this address)