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TeAJV - "', I�T 3/ 16 Applications Will Be P. eRed When Suhmitted Properly Completed. Be , To Sign The Application. 1" OFFICE USE ONLY I ..-__-__ For Calendar Year -�, y4 Multiple Years(Permanent Housing Camps) Area _ Conditional Permit APPLICATION I.D. No.. y (For Non-Transferable, Revocable, Suspendable) Date Approved ENVIRONMENTAL HEALTH PERMIT Permit_.___. TO OPERATE Date Mailed EMPLOYEE HOUSING OR LABOR CAMP New Existing FEE IS DUE WITH APPLICATION Change nFi'rt,ivt�`�t'n . r'AZI Location � � �4 g� .j;H HD. Operator J0 9 P. Address_'�z r .��- -6 - -—--- ss ii�� + !` A- -- Legal Owner LZ` I•' R.�a1A " 1., Telephone. No. Address 2� E STOL'rl✓ R L ;h23� — New Owner Yes X No - - No. Employees Housed 7 _ 0 ephone No Occupancy Dates _-_ From �r To I - - Crop _ From_ To Crop Total Number Days Used This Calendar Year Total Days Ocupied by 25 or more employees_150 days e (Camps occupied by 25 or more employees for 60 or more days require a public water system permit*) I,�.artive 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. r , / FEE SCHEDULE r, (,I u• '. i .t _ Permanent Camps Annual Permit $35.00 + No. Employees�.Z_ $12.00 each = S t All f l !^ L' _ Orchard Camps$95.00 Transfer of Ownership $20.00 Amend Permit $20.00 + Additional EmployeesGd $12.00 eachI , I Late Application Penalty Fee $70.00 + Employees ® $24.00 each = s_ 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 of the Employee i Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. Please remit In the enclosed self-addressed envelope together with applicable fee. DO NOT SEND CASH. - Date Signed X ---- - - - --- - ------- Title - • Contact Environmental Health for information and application for a public rater system ,permit. FOR DEPARTMENT USE ONLY Fl+na Is Due: ❑ANNUALLY ❑ PER UNIT ❑ PER SItE t_� EACH U January 1 A Received By Jan 31 El July 1 A Received B Ju 31 — _ BASE EXPLANATION BILLING REMITTANCE = REMIT DATE DATE REMITTED AMOUNT DUE CHECKED -------— AMOUNT FFE LESS PROnATx)N PLUS PENALTY OTHER OTHER C lj naceived by Osl Reew No. mil N Issuance Dale Mailed Delivered APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PER RVICES P O box 2009 STOCKTON,CA e5201 OFFICE ADDRESS 445 N.SAN JOAOUIN ST..STOCKTON,CA EH-0250(11IN) (NO MAIL IS RECEIVED AT THIS ADDRESS) Phone (209) 468-3420