Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. be Sure To Sign The Application. <br /> OFFICE USE ONLY <br /> For Calendar Year -__. Area <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> Condition�p r It Date Approved_-__—____ <br /> I.D. No. (For Non-Transferable, Revocable, Suspendable) <br /> Permit_-­ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Dale Mailed _ <br /> fK41 <br /> ' j� TO OPERATE <br /> � ��/ v EMPLOYEE HOUSING OR LABOR CAMP New Existing _ <br /> (I '* D34 FEE IS DUE WITH APPLICATION Change <br /> Location Mandeville Island, Stockton, Cal i fnrni a 95219 <br /> Operator CCRC Farmc;, T,T.0 <br /> Address P.O. Box 248 1401 t, CA 95214 Telephone No. 2flq 4F,4 2g5g <br /> Legal Owner _CCRC Fa rmS, LIP <br /> New Owner Yes XY_ No <br /> Address.--`- P.0 Box 248 Hnl t, (-A- C352-14 _ Telephone No._ 2Qq 464 2g5q <br /> No. Employees Housed 15 Occupancy Dates From January 1 To.DeCeliber 31 Crop.Q.apes <br /> From_ To Crop _ <br /> Total Number Days Used This Calendar Year - 365 <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 carnp 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 /> yy_ Permanent Camps Annual Permit $35.00 + No. Employees _-15— a $12.00 each = <br /> Orchard Camps $95.00 -- Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + -_ Additional Employees (a S 12.00 each = <br /> Late Apnilcatlon Penalty Fee $70.00 + Employees (a $24.00 each = <br /> Applicaw agrees to all necessary Inspections Incident to issuance of permit to operate. <br /> Applicant agrees that this pro)Ttct shall be operatrxl and mnintnined in accnrdanrn 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, SubchRpter 3, Title 25, CCR. <br /> Please remit in the enclosed solf-addressod envelope togeth ith applicable fee. DO NOT SEND CASH. <br /> Date---I 1-12-9 '-""�� <br /> �_ Signed X --�"'^"-"`�- Title -_Gerlera.L.Manager ___-_-- -_ <br /> Contact Environmental Health for information and application for <br /> a public water system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: U ANNUALLY ❑ PER UNIT [, PER SITE — ❑EACH ❑January I A necoived By.lanuery 3t ❑July 1 a necah•ed By July 31 <br /> BILLING REMITLANCF _--- S - - REMIT <br /> BASE EXPLANATION DATE DATF REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ----- ------- --- ------- -- <br /> PRORATION <br /> PLUS -------------- --- -- ------- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Ieavar,ce Date Melted Delivered <br /> APPLICANT— RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Post Office Rimy 'RR Stockton, CA 95201-0398 <br /> Office Address <br /> 304 E. Weber Avenue, Third Floor EH-0250(11/88) <br /> Stockton, CA 95201 Phone (209) 462-3420 PHS179 (4/96) <br /> (No mail is received at this address) <br />