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Applications Will Be I _sed When Submitted Properly Completed. Bk To Sign The Application. OFFICE USE ONLY For Calendar Year G Area Multiple Years (Permanent Housing Camps) APPLICATION Date Approved Conditional Permit I.D. No. _'� (For Non-Transferable, Revocable, Suspendable) Permit ENVIRONMENTAL HEALTH PERMIT Date Mailed _ / I TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP New Existing FEE IS DUE WITH APPLICATION Change Location Operator Address Telephone No. Legal Owner New Owner Yes No Address Telephone No. No. Employees Housed Occupancy Dates 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 = Orchard Camps$95.00 Transfer of Ownership $20.00 Amend Permit $20.00 + Additional Employees ® $12.00 each = $ P Late Application Penatty Fee $70.00 + Employees ® $24.00 each = $_ �FC Applicant agrees to all necessary inspections incident to issuance of permit to operate. FEB (j 996 Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of th Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, t*P�l ,1 l ( U3,; ENVIRpNME LTH SEf ; Eq Please remit in the enclosed self-addressed envel tog her wi ap71i;able fee; DO NOT SEND CASH. NTAL HE ?Vf�ES �' ACTH DIVISION Date , F� Signed X ✓ ",Title Contact trivironmental Health for information and application for a public water system permit. FOR DEPARTMENT USE ONLY Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jams 31 ❑Juty 1&Received B J�uy 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS N PLUS TY OTHER _ OTHER Received by Data pt No. Permit No. Issuance Data &Wed Dekvwed APPLICANT—FETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES P.0. Box 388 Stockton, Ca. 95201 OFFICE ADDRESS 445 N.SAN JOAOUIN ST.,STOCKTON.CA phone (2 0 9 ) 468-3420 EH-0250 (11/94) (NO MAIL IS RECEIVED AT THIS ADDRESS)