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Applications Will Be Pro,.. seed When Submitted Properly Completed. Be . : To Sign The Application. <br /> OFFICE USE ONLY <br /> _ For Calendar Year (,w ovZS 3 aa, <br /> Area <br /> Multiple Years (Permanent Housing Camps) <br /> _ Condition I er it <br /> Date Approved <br /> I.D. No. 14 APPLICATION Permit <br /> (For Non-Transferable, Revocable, Suspendable) Date Mailed <br /> 0V3I ENVIRONMENTAL HEALTH PERMIT New Existing <br /> lJ TO OPERATE <br /> Change <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> �FEE IS DUE WITH APPLICATION <br /> Location ° <br /> Operator <br /> Address ffl 2k �00 Telephone No. <br /> Legal Owner t S New Owner Yes -/ No <br /> IJ <br /> Address _ Telephone No. <br /> No. Employees Housed Occupancy Dates f 5 U From - _To;Ass•-1 Crop <br /> From V To Crop <br /> Total Number Days Used This Calendar Year <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 Q $12.00 each = $ 1i I/ t__/ <br /> Orchard Camps $95.00 _ Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + _ Additional Employees $$12.00 each = $ �T <br /> Late Application Penalty Fee $70.00 + Employees $24.00 each = $ <br /> J A N 5 1996 <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 SEITVICES <br /> Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. 4LTH <br /> D <br /> `/ VISIUN <br /> Please r mit in the enc sed self-addre ed envelope together With applicable fee. DO NOT SEND CASH. - a" <br /> Date t�• Signed X Title L <br /> FOR DEPARTMENT USE ONLY I J <br /> Fees is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> it No. Issuance Date Mailed Delivered <br /> NEW OFFICE & MAILLING ADDRESS -EEMIT/SERVICES P o Box 2009 STOCKTON,CA 95201 <br /> 304 EAST WEBER AVENUE, STOCKTON CA EH-0250(11188) <br /> (No Mail Received At This Address) <br /> P . 0. BOX 388 , STOCKTON CA 95201 <br />