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Applications Will Be P6sed When Submitted Properly Completed. Be To Sign The Application. F//�� `D 0 ( � OFFICE USE ONLY For Calendar Year 11 s F/C 0 a 7 (Y Area Multiple Years(Permanent Housing Camps) APPLICATION Conditional Permit Date Approved I.D. No. (For Non-Transferable, Revocable, Suspendable) Permit ENVIRONMENTAL HEALTH PERMIT Date Mailed _ TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP New Existing FEE IS DUE WITH APPLICATION Change Location Mandeville Island, Stockton, CA 95219 Operator CCRC Farms Address P.O. Box 248 Telephone No. 209 464 2959 Legal Owner Same New Owner Yes XX No Address Same Telephone No. 209 464 2959 No. Employees Housed 43 Occupancy Dates From March 1 To May 1 Crop%sparsaus From January 1 To December 31 Croorapes Total Number Days Used This Calendar Year 365 Total Days Ocupied by 25 or more employees 50 • (Camps Occupied by 25 or more employees for 60 or more days require a public water system permit*) 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 returned marked "Inactive" too protect your land use status. FEE SCHEDULE Permanent Camps Annual Permit$35.00 + No. Employees 43-- $12.00 each = _ Orchard Camps$95.00 Transfer of Ownership $20.00 Amend Permit $20.00 + Additional Employees ® $12.00 each = _ -X Late Application Penalty Fee $70.00 + .5-0 Employees $24.00 each = $ l 2 76,.CY-7) Applicant agrees to ail necessary inspections incident to issuance of permit to operate. Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Employee Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. Please remit in the enclosed self-addressed envelope to ether with applicable fee. DO NOT SEND CASH. i)AYME5 Date 3-31-95 Signed Title it", % fix Contact Environmental Health for information and application for APR � � �99� a public waters stem permit. SAN I r_ r�T, FOR DEPARTMENT USE ONLY PUBLIC HEALTH pSERVICES Fees Is Due: [I ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH El January 1 a Received By January 31 I'�1JL M HY�eI�Yd'By J�.91LTH 0 V I S I O BILLING REMITTANCE S REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS P T N _ PLUS PENALTY OTHER OTHER !ied!by� L -1.-tr Received!by Dale ' Receipt No. P mit No. Issuance Data MaY�]W OeYrwad APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES P.O. BOX 38 8 Stockton, Ca. 95201 OFFICE ADDREss /�J EH-0 2 5 0 (11/9 4) 1 N.SAS RECEIVE ST.,$T D CA (NOO MAIL IS RECEIVED AT THISS ADDRESS) Phone (2 0 9) 4 6 8-3 4 2 0 ESS) S'/)