BILLING - Laserfiche WebLink

Home Browse Search

Applications Will Be PrL A When Submitted Properly)Completed. Be St o Sign The Application. a` +(10 OFFICE USE ONLY _ For Calendar Year O Area Multiple Years tPermanent Housing Camps) APPLICATION Conditional Permit Date Approved _ 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 DUE WITH APPLICATION /Change Location BACO-..1 =tslJ-r,)D C'ANlT 3 _ tiJ nl..! CIA/.!P - � /is OperatorSw1z Address�Y PxbC 343 =TIb Cw IT?.1 C'q 326 ( Telephone No. Legal Owner Di L-rj%1 W C`% •N DS New Owner Yes No Address - L 9't r-1T FiLVJ�l 'Jr 32v L&1-�It-TTF� Telephone No. -.10 R�3 '/1 IG No. Employees Housed - S! Occupancy Dates From _ To Crop r'f trJ From To Crop Total Number Days Used This Calendar Year Total Days Ocupled by 23 or mora employees (Camps Occupied by 33 or more employees for 60 or mora 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 Permanent Camps Annual Permit $35.00 + No. Employees — _ a $12.00 each = $ 6/Z. 4oJ c 6'11'- Orchard `7 1'Orchard Camps $95.00 _ Transfer of Ownership $20.00 Amend Permit 520.00 + -- Additional Employees d $12.00 each - $ Late Application Penalty Fee $70.00 + Employees ® $21.00 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 of the Employee Housing Act, Chapter 1, Pan 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCN. Please remit in the enclosed self-addressed envel9pe,together withplicable fee. DO NOT SEND CA T. Date . � .�.� :� : � Signed X ( Title i :e • Contact Clvlrortmental Health for information am atiplication for a public water system permit. FOR DEPARTMENT USE ONLY Fan Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑imv.q I A R.,N January 31 ❑Ju 1 8 RecN.ed J BILLING REMITTANCE a REWT BABE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LEea TION PLU9 TV OTHER OTHER R.Ned by DO. Recoo No. Parton No. Ique Dee NAWd Dewend APPLIDAHT—RETURN ALL COPM TO ENwIRONYENTAL HEALTH PERm1T1SERVICES P.O. Box 388 Stockton, Ca. 95201 O"ICE ADDRESS 445 N.SAN JOAOUIN ST.,STOCKTON,CA phone (209 ) 468-3420 EH-0250 (11/94 ) (NO MAIL IS RECEIVED AT THIS ADDRESs)