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Applications Will Be Proms_ sed When Submitted Properly Completed. Be SL. To Sign The Application. ;/2j// <br /> OFFICE USE ONLY <br /> For Calendar Year <br /> Area _ <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> —_ Conditional Permit. Date Approved_- <br /> ---? <br /> I.D. No. (For Non-Transferable, Revocable, Suspendable) <br /> Permit <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Date Mailed <br /> TO OPERATE <br /> EMPLOYEE HOUSING New Existing <br /> FEE IS DUE WITH APPLICATION Change 001-111--3 <br /> Location IWOCV I At d. <br /> Operator <br /> Address Telephone N <br /> Legal Owner L QA A I tr ►n lr• (Q n New Owner Yes -Y. — No <br /> Address Telephone No. LvvvA— <br /> No. Employees Housed r— Occupancy Dates From To AJoV . Crop <br /> AG'I�� Iry / F 1/ /�Vn l From To Crop <br /> �J.7 fl 1 Total Number Days Used This Calendar Year <br /> PqTotal Days Ocupied by 25 or more employees f!T✓l'� • <br /> R� Y �Ae.r (Camps Occupied by 25 or more employees for 60 or more days require <br /> Clif el a public water system permit*) <br /> Inactive — IMPORTANT. If this campArVrg8 Jo` 4"his year but is intended for use in the future, this application is to be <br /> returned marked I � }i{��It�oi` �Afg (yep�7 nd use status. <br /> ►'lMQn1MfNTgL klEA E`�SCHEDULE <br /> h`IvfJ II,n, C <br /> Permanent Camps Annual Permit $35.00 + No. Employees L ® $12.00 each = $ 5 5 <br /> Orchard Camps $95.00 Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + Additional Employees ® $12.00 each = $ <br /> /1 /1 Late Application Penalty Fee $70.00 + Employees r@ $24.00 each = $ <br /> `\� J Applicant agrees to all necessary inspections incident to issuance of permit to operate. <br /> _b Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Employee <br /> (n 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 applicable fee. DO NOT SEND CASH. <br /> Date Signed Title <br /> Contact Environmental Real 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 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by I f Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES P O Box 2009 STOCKTON,CA 95201 <br /> OFFICE ADDRESS EH-0250(11/88) <br /> 445 N.SAN JOAQUIN ST..STOCKTON,CA <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 468-3420 <br />