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Applications Will Be P.,,_, ssed When Submitted Properly Completed. Be To Sign The Application. <br /> OFFICE USE ONLY <br /> For Calendar Year Area <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> Conditional Permit Date Approved <br /> I.D. No. (For Non-Transferable, Revocable, Suspendable) permit <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Date Mailed <br /> TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP New Existing <br /> FEE IS DUE WITH APPLICATION '- <br /> n <br /> Change h C? 7-J '9 2. <br /> s;ndc-.ri.1_1e Island, St {tr.n <br /> Location <br /> Operator -CRC Farms <br /> Address �' 'ox 248 Holt° C �)234 Telephone No. 90 <br /> n. <br /> Legal Owner New Owner Yes XX�t t11 No <br /> Address Telephone No. <br /> �Z •�9 <br /> No. Employees Housed Occupancy Dates From 82'Q To Crop' $�a' <br /> From '.riZt.F2Y To � E' P <br /> C @` Cro ..r8.1 f <br /> Total Number Days Used This Calendar Year <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 camp 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 /> Permanent Camps Annual Permit $35.00 + No. Employees _ C� $12.00 each = $ 111;5.`00 <br /> Orchard Camps $95.00 Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + Additional Employees a $12.00 each = $ <br /> Late Application Penalty Fee $70.00 + Employees ® $24.00 each = $ <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 Applicable provisions of the Employee <br /> Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. <br /> Please remit in the enclosed self-addressed envelope together with applicable fee. DO NOT SEND CASH. <br /> Date Signed X Title <br /> • Contact Environmental Health for information and application for <br /> a public water system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE 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. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES P 0 Bolt 2009 STOCKTON,CA 95201 <br /> OFFICE ADDRESS <br /> EH-0250(11/88) <br /> 445 N.SAN JOAOUIN ST.,STOCKTON,CA <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 468-3420 <br />