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Applications Will Be PI sad When Submitted Properly Completed. Be , To Sign The Application. /For Calendar Year 4 ,OFFICE USE ONLY ��1'� � /: Multiple Years (Permanent Housing Camps) Area Conditional Permit APPLICATION Date Approved I.D. No. ..39-3..21 (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 �C �G' E ,� }�f tr �C{ L /i1 �C�l 2t4 Y15�-3 Operator S.¢ i 4— p Address Telephone No. Legal Owner ZLi��i r��c� s{y�,f��y New Owner Yes X No Address - Telephone No. No. Employees Housed r/d Occupancy Dates From D r I To_ ., r.,... I/ From To Crop �Q 117 i�t� 7+O tlS�/1� Total Number Days Used This Calendar Year / Total Days Ocupiod by 23 or more employees (Camps occupied by 23 or more employees for 60 or more days require a public water system permits) 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 10 ® S12.00 each - = s t Od Orchard Camps$95.00 Transfer of Ownership $20.00 Amend Permit S20.00 + Additional Employees a $12.00 each - _ y.z Late Appllcatlon Penatty Foe $70.00 + Employees ® $24.00 each - S 0 1996 JUN Applicant agrees to all necessary inspections incident to issuance of permit to operate. SAN juUAQUN ,.,U,.).dl 1 Applicant agrees that this protect shall be operated and maintained in accordance with the Applicable provisions of the,__ rH SERVICES Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1. Subchapter 3 rTu�g�e Jdjj u �HEALTH DIVISION Please remit in the enclosed self-addre envelope together wit=�Pblefee. OT SEND CASH. Date ' 15 Signed s Contact Environmental Health Car information and application for A public water system permit. FOR DEPARTMENT USE ONLY Fees Is Due: ❑ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By Jams 31 ❑JutV 1 a Received BX J 31 BASE EXPLANATION BILLING REMITTANCE S REMIT DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LE93 P N PLUS iV OTHER OTHER V4 a6 bl' D Receipt No, Permit No., issuance Dee Muted 0e4vered - AFPLICANT—RETUIIN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMITISERVICES P.O. BOX 388 Stockton, Ca. 9520 OFFICE ADDRESS 445 N.SAN JOAOUIN ST.,STOCKTON,CA phone (2 0 9 ) 4 6 8-3 4 2 0 EH-0 2 5 0 (11,/9 4 (NO MAIL IS RECEIVEO AT THIS ADOREssI