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Applications Will Be Proce�ned When Submitted Properly Completed. Be S o Sign The Application. fKA 0000 3 l/I OFFICE USE ONLY For Calendar Year Pr 0 a-q oV� Area Multiple Years(Permanent Housing Camps) APPLICATION 1 Date Approved Conditional Permit I.D. No. ' (For Non-Transferable, Revocable, Suspendable) Permit ENVIRONMENTAL HEALTH PERMIT Date Mailed _ TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP New Existing FEE IS UE WITH APPLICATION Change Location c Operator y Address t i/' 4 �: Telephone No. Legal Owner New Owner Yes No Address C Tel e one No. No. Employees Housed Occupancy Dates 6 1 From To From To Crop r Total Number Days Used This Calendar Year Total Days Ocupied by 25 or more employees • (Camps Occupied by 25 or more employees for 60 or more days require a public water system permit*) 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 returned marked "Inactive" too protect your land use status. \/ FEE SCHEDULE A Permanent Camps Annual Permit $35.00 + No. Employees7f_ ® $12.00 each = $ b D Orchard Camps$95.00 Transfer of Ownership $20.00 Amend Permit $20.00 + Additional Employees ® $12.00 each = III Late Application Penalty Fee $70.00 + Employees (a $24.00 each = _ Applicant agrees to all necessary inspections incident to issuance of permit to operate. Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions 0A Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, 01 T Please remit in the enclosed self-addressed envelope together w h applicable fee. DO NOT SEND CASK." 1 " Date Signed X Title SAN ..y AraU l N CqU NTY Contact Environmental Realth t r information and application for PUBLIC HEAL,1 H SrFWJC�S a public water system permit. ENViIR(ONMEPd1>r Hkc !_-rH DlViaiON FOR DEPARTMENT USE ONLY Fees Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jan u 31 ❑ Juty,1 a Recdwd B July uy 31 BILLING REMITTANCE $ REMIT -15E--- EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE -1 LESS / P T1 N _ PLUS TY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date MWad Dowered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES P.O. BOX 388 Stockton, Ca. 95201 OFFICE ADESS 445 N.SAN JOAOUIN ST..STOCKTON,CA EH—0 2 5 0 (11/9 4) (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone ( 2 0 9) 4 6 8—3 4 2 0 �/�� LJ/