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Applications Will Be P,_ eased When Submitted Properly Completed. Be _.e To Sign The Application. <br /> OFFICE USE ONLY <br /> For Calendar Year � t I&� Area <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> _—_ Conditional Permit Date Approved <br /> I.D. No. (For Non-Transferable, Revocable, Suspendable) <br /> 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 Change <br /> Location <br /> i <br /> Operator <br /> Address Telephone No. <br /> Legal Owner New Owner Yes No <br /> Address Telephone No. <br /> No. Employees Housed fQ Occupancy Dates From %1i� J! To-��n��l , Crop Cl <br /> From To Crop _ <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 � ® $12.00 each = $ <br /> Orchard Camps $95.00 Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + Additional Employees ® $12.00 each = $ <br /> Late Application Penalty Fee $70.00 + Employees (a $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 /> y/ <br /> Date i rj•�" Signed X —�- — Title �' ! <br /> + Contact Environmental Realth 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 8 Received By January 31 ❑ July 1 8 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 /> R iv by bate Receipt N . Permit No. Issuance Date Mailed .Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTWPERMIT/SERVICES P 0 Box 2009 STOCKTON,CA 95201 <br /> OFFICE ADDRESS EH-0250(11/S8) <br /> 445 N.SAN JOAQUIN ST.,STOCKTON,CA <br /> k . <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 462-3420 <br />