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Applications Will Be r,..eessed When Submitted Property Completed. Be Sure To Sign The Applleadorl_ <br /> ENVIP <br /> AU <br /> For Calendar Year�_ �� AreaT'::T r•rm....,_ <br /> Multiple Years (Permanent Housing Camps) <br /> OG Oata-Approvep'i 1 <br /> Conditional Permit <br /> I.D. Na. //Q APPLICATION <br /> _ Pannit <br /> (For Non-Transferable, Revocable, Suspendable) Date Mailed <br /> ENVIRONMENTAL HEALTH PERMIT New_Existing <br /> TO OPERATE <br /> Change <br /> EMPLOYEE HOUSING OR LABOR CAMP ' <br /> FEE IS DUE WITH APPLICATION <br /> LocationC�l j+n-+'•.+'+ —h'l1Lt'.I "'.""t' _ <br /> Operator IL�{'�YJL RaQ.N C_ <br /> Add= ?2 =M C-& !iSZo I Telephone No. '`kms-797 1 - <br /> Legal Owner -Ds=LT WEVI.-A.rl1t ��,�,,/ New Owner_Yes ,e—No <br /> Address a,-4:1 1-LT of"ta P.�LYD -ra+ .7UO !�� CA Telephone No. 46Jo) 4�n -,l� <br /> No. Employees Housed -t-1 Occupancy Dates Fmm J/� To D6c: Crop QoUj <br /> 1 Fram Ta Crop <br /> Total Number Days-Used This Calendar Year 3(P0 <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 /> retumed marked "Inactive" too protect your land use status. . If <br /> dUa�. DU- --12 pW/le <br /> FEE SCHEDULE INtx �? . <br /> )< Permanent Camps Annual Permit$35.00 + No.Employs"s1 ® 512.00 each <br /> Orchard Camps $95.00 Transfer-of Ownership $20.00 _ <br /> Amend Permit$20.00 + Additional Employees ® S12.00 each =S <br /> Late Application Penally Fee S70.00 + Employees a 524.00 each s SPAyMFNT <br /> RECE"Y'P" <br /> Applicant agrees to all necessary Inspections incident to Issuance of permit to operate. EC 14 1995. ' <br /> Applicant agrees that this protect shell be operated and maintained in accordance with the Applicable provisions the che.Ent <br /> Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchap4'7.uTt114 <br /> PUBLIC H VVICES - <br /> Please remit in the enclosed salt-add en Icp roger er wtm eppurable ree: oo NorsEtvt7HA�TALHEALTHDIVISION• <br /> v <br /> , r <br /> Date_Signed X Title &7 <br /> FOR DEPARTMENT USE ONLY <br /> Fees 1a Due: ❑ M,,,A Y ❑ VEA unit OPER 9 ❑ EACH ❑Jr 1 8 A. eT J..Jt A A•oNIJ eT Jw a1 <br /> REMIT <br /> RASE tDU'l.V1ATIWr eDATE R�DATE RFJAI A UNT DUE AYIXINT <br /> FEE <br /> LESS <br />� M7pN <br /> P us <br /> ALL <br /> OTNEA <br /> On1EA <br /> Lr�lmu,. f?/r�14S � e4a�8! <br /> Y1NI Np IrrulrKl 001 YWM D•h•,11 <br /> IEW OFFICE & MAILLING ADDRESS NP WT/s VICES P o Sox 2009 STOCKTON,G rsm, <br /> 04 EAST 'WEBER AVENUE, STOCKTON CA e+nasbouael <br /> No Mail Received At This Address) <br /> . 0. BOX 388 , STOCKTON CA 95201 <br />