Laserfiche WebLink
Applications WIII Be F.. _eased When Submitted Properly Completed. Be _ ,•e To Sign The Application. <br /> y/?b_3 <br /> OFFICE USE ONLY <br /> For Calendar Year -'" ~ I Area <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> —_ Conditional Permit. Date Approved <br /> I.D. No. (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 /> FEE IS DUE WITH APPLICATION Change <br /> (Location Qd <br /> Operator <br /> "Address Telephone No <br /> Legal Owner New Owner Yes �_ No <br /> Address r' Telephone No. <br /> No. Employees Housed _o6cupancy Dates YQGr/y From To Cr <br /> From To Cr <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 /> Permanent Camps Annual Permit $35.00 + No. Employees _ ® $12.00 each = $ <br /> Orchard Camps $95.00 Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + Additional Employees ® $12.00 each = $ <br /> Late Application Penalty Fee $70.00 + Employees g $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 applicable fee. DO NOT SEND CASH. <br /> Date 5elSigned ,��4 r.�:!� Title O t__2� <br /> + Contact Environmental Reath 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 f <br /> PRORATION <br /> PLUS <br /> PENALTY "�•�.%'/"C <br /> , 1 ) I <br /> OTHER [.C _ �— -c/ Z3Q 0� <br /> OTHER <br /> Received by 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 o250(t t/ee) <br /> 445 N.SAN JOAOUIN ST.•STOCKTON.CA <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 468-3420 <br />