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Applications Will Be P*sed When Submitted Properly Completed. Be To Sign The Application. � G <br /> �-. <br /> > 1G <br /> T -7�>/i' OFFICE USE ONLY <br /> For Calendar Year Area <br /> Multiple Years(Permanent Housing Camps) APPLICATION <br /> Conditional Permit Date Approved <br /> I.D. No. 3 F-321 (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 /> n FEE IS DUE WITH APPLICATION Change <br /> Location 410t2,o E /fl1 Jr �G�. �/�► R�C/I Ild 9 3� <br /> Operator S On I _ <br /> Address O / / Telephone No. 1 / G� �•�5 <br /> Legal Owner ZA4a re-'/ q New Owner Yes X No <br /> Address Telephone No. <br /> No. Employees Housed /O Occupancy Dates From ftrI To A - Cro ` a-r-,4S <br /> G I/ 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 /> it <br /> Permanent Camps Annual Permit $35.00 + No. Employees /G ld $12.00 each = S 6 <br /> Orchard Camps $95.00 Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + Additional Employees ® $12.00 each = S <br /> Late Application Penalty Fee $70.00 + Employees ® $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 appl' ble fee. DO NOT SEND CASH. <br /> Date , /3 ` Signed ria�_ <br /> e <br /> + Contact Environmental Health 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 a Received By Jan u 31 ❑ Juty 1 a Received B Jy my 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> P N _ <br /> PLUS <br /> PE TY <br /> OTHER <br /> OTHER <br /> s a clsa6 ! , <br /> Raceive0by DA@ Receipt No. Permit No. Issuance Dole Ma"d DeQverad <br /> APPLICANT—IETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES P.O. Box 388 Stockton, Ca. 95201 <br /> OFM ADESS <br /> 445 N.SAN JOAOUEN ST..STOCKTON,CA M—0 2 5 0 (11/9 4) <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (2 0 9 ) 4 6 8—3 4 2 0 <br />