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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FUI.1i701iOFFIGEyUSED )_ <br /> For Calendar Year 11,7(0hi:Al fit <br /> Area <br /> Multiple Years(Permanent Housing Camps) <br /> Conditional Ps it _^,mare-Approvep y�T <br /> F„ ! jU• <br /> naT� <br /> I.D. No. llQ APPLICATION Permit <br /> C6 l (For Non-Transferable, Revocable, Suspendable) Date Mailed <br /> ENVIRONMENTAL HEALTH PERMIT New_Existing <br /> r7d a1gT(O TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP Change <br /> FEE IS DUE WITH APPLICATION <br /> Location <br /> Operator <br /> Address—F�'J� 3 ::;IIaC.C7b.3 CA !SZO 1 Telephone No. #61�-79751 <br /> Legal Owner D4Ltayjf:-La... r New Owner_Yes %,f No <br /> Address 36q, L-tT Zito, .o t?,L1r.D 11LO L6ET / f{C CA Telephone No. iED) .,711_;-/1J41- <br /> No. Employees Housed .?"/ Occupancy Dates From To ,D6C_ Crop Qoto <br /> From To Crop <br /> Total Number Days Used This Calendar Year 360 <br /> a <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 —f/ ® $12.00 each = $ <br /> Orchard Camps$95.00 Transfer of Ownership $20.00 <br /> Amend Permit$20.00 + Additional Employees ® $12.00 each = 3 <br /> Late Application Penalty Fee $70.00 + Employees 0 $24.00 each = 3a�IFNT <br /> Applicant agrees to all necessary Inspections incident to issuance of permit to operate. ULC 14 1995 <br /> Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Em <br /> Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Cade and Chapter 1, Subchapte?3;�TIt14'�CR- <br /> PUBLIC HEAL H bcR`ll,�cs <br /> Please remit in the orposed selfaddre on to toget er with applicable fee. DO NOT SOW COWENTAL HEALTH DIVISiC"l <br /> r <br /> Date n" Signed X Title <br /> FOR DEPARTMENT USE ONLY <br /> Fees Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑J..0 t A RepNeE ey January Jt ❑ July,6 R W a July w <br /> BILLING REMITTANCE 5 REMIT <br /> BASE EXPLANATIONDATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PR TION <br /> PeNA <br /> P N TY <br /> OTHER <br /> OTHER <br /> l�tawr� I�/Iv19S Ck4a�81 <br /> vma No. bwrre Dm Mw DaNrerW <br /> NEW OFFICE & MAILLING ADDRESS NPERWISMIRCES P o box 2OO9 STOCKTON,CA"=I304 EAST WEBER AVENUE , STOCKTON CA EH42W(IIM) <br /> (No Mail Received At This Address) <br /> P. 0. BOX 388 , STOCKTON CA 95201 <br />