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Applications Will Be Pr, ad When Submitted Properly Completed. Be ` Ication. <br /> OFFICE USE ONLY <br /> t For Calendar Year <br /> p ( g p ) APPLICATION Multiple Years Permanent Housing Cams a Approved <br /> Conditional Permit. <br /> I.D. No. t <br /> 0 (For Non-Transferable, Revocable, Suspendable) mit <br /> ENVIRONMENTAL HEALTH PERMIT I e Mailed <br /> TO OPERATE <br /> w Existing <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> r <br /> FEE IS DUE WITH APPLICATION ange <br /> Location <br /> Operator <br /> Address JNewOwn <br /> Legal Owner No <br /> Address No. Employees Housed Occupancy Dates From Crop <br /> From _Crop <br /> Total Number Days Used This <br /> Total Days Ocupied by 25 yeas • <br /> (camps occupied by 25 or for 60 or more days require <br /> a public water system pe <br /> Inactive — IMPORTANT. If this camp is not to be used this year but is intended for re, 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 g <br /> Orchard Camps$95.00 Transfer of Ownership $2 <br /> Amend Permit $20.00 + Additional Employees @ <br /> Late Application Penalty Fee $70.00 + Employees @ <br /> Applicant agrees to all necessary inspections incident to issuance of permit to opera <br /> Applicant agrees that this project shall be operated and maintained in accordance with the ns of the Em <br /> Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chal , I e 25. CCR. <br /> Please remit in the enclosed self-addressed envelope together with applicable fee. I 1SH. <br /> Date Signed X <br /> Contact Environmental Health for information and application fo1 <br /> a public water system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R( ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AOUNT DUE CHECKED <br /> DATE DATE I AMOUNT <br /> FEE y <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Dat Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES )9 STOCKTON,CA 95201 -- <br /> OFFICE ADDRESS EH-02 <br /> 445 N.SAN JOAQUIN ST..STOCKTON,CA <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Pho- a (209) 468-3420 <br /> I <br />