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�Applications WIII Be Processed When Submitted Proplerly Completed. Be Sure To Sign The Application. I Zh1q OFFICE USE ONLY For Calendar Year Area _ Multiple Years(Permanent Housing Camps) APPLICATION Conditio m1 ]� Date Approved 1.D. No. l 0 (For Non-Transferable, Revocable, Suspendable) Permit ENVIRONMENTAL HEALTH PERMIT TO OPERATE Date Mailed EMPLOYEE HOUSING OR LABOR CAMP New Existing FEE IS DUE WITH APPLICATION Change Location Operator L OH��1r Vmm,o\�\ Address Telephone No. Legal Owner New Owner Yes L No Address \A(S A Telephone No. _ 7�,1nr No. Employees Housed —�__Occupancy Dates IR IN 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 $35.00 + No. Employees ® $12.00 each = S Orchard Camps $95.00 Transfer of Ownership $20.00 Amend Permit $20.00 + Additional Employees ® $12.00 each = S Late Application Penalty Fee $70.00 + Employees ® $24.00 each = S Applicant agrees to all necessary inspections incident to issuance of permil to operate. Applicant agrees that this project shall be operated and maintained in accordant.,with the Applicable provisions of the Employee Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code rind Chapter 1, Subchapter 3, Title 25, CCR. Please remit in the enclosed self-addressed envelope together with applicable fee. DO NOT SEND CASH. Date 7LL7. 14 Z; YY-Signed X L Title L%Z is t • Contact Environmental Realth"tor information id application for DEL 31996 a public water system parmit. (, U �J I SAN JOAQLAN Ge FOR DEPARTMENT USE ONLY ENVIRON/. qt h�y SERVICES ,p Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 18 Received B January 31 LJ(du�1f1il54&�ed By July 31 BILLING REMITTANCE f REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER _ /- 315 �s- Flece.ad by Date —r Receipt No. Permit No. Issuance Dole Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Post Office Box 3R8 Stockton, CA 95201-0388 Office Address 304 E. Weber Avenue, Third Floor EH-0250(11/88) Stockton, CA 95201 Phone (209) 468-3420 PHS 179 (4/96) (No mail is received at this address)