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r 7/�Applications Will Be*eased When Submitted Properly Completed. r placation. <br /> OFFICE USE ONLY <br /> For Calendar Year I� <br /> Multiple Years (Permanent Housing Camps) APPLICATION as <br /> Conditional Permit ie Approved <br /> I.D. No. L4 (For Non-Transferable, Revocable, Suspendable) <br /> mat <br /> ENVIRONMENTAL HEALTH PERMIT r i <br /> e Mailed <br /> TO OPERATE <br /> /0 3 I o SS EMPLOYEE HOUSING OR LABOR CAMP ` Existing <br /> FEE IS DUE WITH APPLICATION nge <br /> Location <br /> Operator I f 4e <br /> Address 7dk CT Telephone E cl Y Q <br /> Legal Owner �ztF'cC /ors J& ,eZi `-U'OeCrS� New Owner ,� No <br /> Address �c7� /£a�/�{�CC �' R.'t�U.��O �C¢ �f y/` �l _ Telephone P <br /> No. Employees Housed A <br /> 42"L!16ccupancy Dates From tif�ti To _Crop IV ft S <br /> C#,Lbdfr From �/f4 To Crop <br /> Total Number Days Used This Czl 3 6S <br /> Total Oay 2: Jq • <br /> (Camps Occupied by 25 or mot 60 or sore days =equir <br /> a public water system permi <br /> Inactive — IMPORTANT. If this camp is not to be used this year but is intended for us d his application is to be <br /> returned marked "Inactive" too protect your land use status. <br /> FEE SCHEDULE <br /> Permanent Camps Annual Permit S2§-QQ + No. Employees JW @ $12.0 /C p© <br /> Orchard Camps $95.00 Transfer of Ownership $20.00 <br /> Amend Permit$20.00 + Additional Employees ® $12.04 <br /> Late Application Penalty Fee $70.00 + Employees (a $24.0d <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 Applic Employee <br /> Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, 25, CCR.IAEN�y <br /> Please remit in the enclosed self-addressed e lop t ther with applicable fee. DO NOT 1?IF�° 411,1r7 ' <br /> Date _ j 0 Signed X ` Title Id 31999 <br /> • Contact Environmental Health for information and application for <br /> a public water system permit. 4 JOAQUIN COUNTY <br /> IC HEALTH SERVICES <br /> -IENTA[. HEALTH DIVISION <br /> FOR DEPARTMENT USE ONLY <br /> F@@g IS Due: ❑ANNUALLY a PER UNIT PER SITE EACH January t &Received By Jai i 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE S REMIT <br /> DATE DATE REMITTED CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Lb <br /> Z131�r �/238g� <br /> Received oy Date Receiot No. Permit No. Issuance Date A elrvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES p 0 Box 'OCKTON,CA 93201 <br /> OFFICE ADDRESS <br /> 445 N.SAN JOAOUIN ST.,STOCKTON,CA EH-0250(11/88) <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 468-3420 <br />