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- * Applications Will Be Processed When Submitted Properly Completed.PP p y Be Sure To Sign The Application. <br /> OFFICE USE ONLY <br /> For Calendar Year Area <br /> Multiple Years (Permanent Housing Camps) APPLICATION <br /> Condition It Date Approved <br /> I.D. No. —5� (For Non-Transferable, Revocable, Suspendable) <br /> Permit <br /> utv-s- 05jL1A"1q ENVIRONMENTAL HEALTH PERMIT <br /> V l T Date Mailed <br /> O OPERATE <br /> New Existing <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> FEE IS DUE WITH APPLICATION Change <br /> Location <br /> Operator <br /> Address j r Telephone No. <br /> Legal Owner "� New Owner Yes No <br /> Address Telephone No. <br /> No. Employees Housed Occupancy Dates From !Z To jp Crop <br /> ,�i� From To Crop 7' <br /> I 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 (a $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 ® $24.00 each = S <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 :ind Chapter 1, Subchapter 3, Title 25, CCR. <br /> Please remit in the enclosed self-address envelope together wittyabplic.Qe fee. DO NOT SEND CASH. <br /> 1. /1 <br /> Date ) Signed X -_ '-- 1(� C� Title r <br /> _Z;z i <br /> • Contact 13tvironsental Health toy information and application for (•,r114`a <br /> a public water system permit. <br /> ,BAN 71997 <br /> FOR DEPARTMENT USE ONLY AN JOAOUIN 0004TY <br /> PLIclt9 ��4 <br /> Fees I8 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ElJanuary 1 6 Received By lenUs[y 31f3 I rvep,§I duly 31 <br /> �E.iF; �E►A Ir; ,,;•. <br /> BILLING REMITTANCE S �+'� <br /> BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CRECItpO- <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. lasuence Dole Mellwd Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES Post Office Box 399 Stockton, CA 95201-0388 <br /> Office Address <br /> 304 E. Weber Avenue, Third Floor EH-0250(11188) <br /> Stockton, CA 95201 Phone (209) 468-3420 PHS179 (4/96) <br /> (No mail is received at this address) <br />