BILLING - Laserfiche WebLink

Home Browse Search

E _ r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. OFFICE USE ONLY For Calendar Year Area _ Multiple Years (Permanent Housing Camps) APPLICATION Conditional Permit Date Approved I.D. No. (For Non-Transferable, Revocable, Suspendable) Permit ENVIRONMENTAL HEALTH PERMIT TO OPERATE Date Mailed EMPLOYEE HOUSING OR LABOR CAMP Ne°v Existing FEE IS DUE WITH APPLICATION Change Location 1,ae�0 )k)QC1 3M Operator Address_�n_f; �i��'1b� 1�C1\r�F \.C \��i" �'11\ _ Telephone No. Legal Owner VAMa\1CA.)4 New Owner Yes _Y No Address -.1,•`�ZP -T)Q\\1F CA, '� ��a�a Telephone No. iloR.�,Aoa No. Employees Housed __Occupancy Dates Ta. •,_ From To Crop From To Crop Total Number Days Used This Calendar Year Total Days Ocupied by 25 or more employees • (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 535.00 + No. Employees 0 $12.00 each = $ Orchard Camps $95.00 Transfer of Ownership $20.00 Amend Permit $20.00 + Additional Employees ® $12.00 each = $ Late Application Penalty Fee $70.00 + Employees ® $24.00 each = $ Applicant agrees to all necessary inspections incident to issuance of permit to operate. Applicant agrees that this project shall be operated and maintained in accordanc:,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 together with applicat,le fee.. DO NOT SEND CASH. HY Date i :.ti f '/ i��L•Signed X �,i . 4/r-'Title E�� 4 • Contact Environmental Realth for information and application for 1996 a public water system permit. r U L i.4(J Jl f It;0tjNTV FOR DEPARTMENT USE ONLY PUBLIC ��,ppHEALTH ��SERVICES Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January 1 8 Received By Janu ryl'3'1��'-L']IJU7�-t��-�bs�vi,' WV46EON BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—BURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Post Office Box 388 Stockton, CA 95201-0388 Office Address 304 E. Weber Avenue, Third Floor EH-0250(11188) Stockton, CA 95201 Phone (209) 468-3420 PHS 179 (4/96) (No mail is received at this address)