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Applications Will Be Pr, Jaeu When Submitted Properly Completed. Be S-e Sign The Application. <br /> OFFICE USE ONLY <br /> —t For Calendar Year I q�S Area <br /> Multiple Years(Permanent Housing Camps) APPLICATION <br /> Conditional Permit <br /> Date Approved <br /> I.D. No.,Z (For Non-Transferable, Revocable, Suspendeble) <br /> Permit <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Date Mailed <br /> TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP New_Existing <br /> FEE IS DUE WITH APPLICATION Change <br /> Location. a4C.o.�l Laia..� C'Ae-LP 3 A.latnl CAA.L <br /> Operator <br /> AddressDn P113G 3AFd �tc:Cf ToJ !'ca �.�Zi i Telephone No. AA-1-711n <br /> Legal Owner Dtf-Tia ND!, New Owner Yee `-A No <br /> Address 56 c ►- j�vAPJal:, 3 LA N- ( Telephone No.l',67C) -�iJ3 --VA <br /> No. Employees Housed �� Occupancy Dates From To ix-_-G Crop "Jet; <br /> From To Crop <br /> Total Number Days Used This Calendar Year .34:n <br /> Total Days Ooupied by 23 or more employees <br /> (Camps Occupled by 23 or mora employees for so or more days -;Quirs <br /> a public eater system peraitq <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 /> X Permanent Camps Annual Permit $35.00 + No. Employees✓ / ® $12.00 each = If 61Z- <br /> Orchard <br /> 1LOrchard Camps $95.00 Transfer of Ownership$20.00 <br /> Amend Permit $20.00 + Additional Employees ® $12.00 each - $ <br /> Late Application Penally Fee$70.00 + Employees a 324.00 each = $ <br /> Applicant agrees to all necessary inspections incident to issuance of permit to operate. <br /> Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Employee <br /> Housing Act, Chapter 1, Pan 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. <br /> Please remit in the enclosed self-addressed env@ toget r with pplicable fee. DO NOT SENO CASH. <br /> f 1 Date{�C1 rC]�I Signed X Title F,✓tee v" <br /> Contact Environmental Health for information and ppiLciatLon for <br /> a public eater system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fees is Due: 0 ANNUALLY ❑ PER UNIT ❑ PEn SITE ❑ EACH ❑ Jwuwy1 a RacaNw By January 31 ❑ July t a RecMvd er Jut,31_ <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> REW <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALT'( <br /> OTHER <br /> OTHER <br /> Realr"by Dau PACMIX No. Pemld No. laurtca Dna Mailed tLatwea <br /> APPLICANT_1ETiM ALL sono To: EMPA)M LWAL HEALTH PeF*W/SMICU P.O. Box 388 Stockton, Ca. 95201' <br /> DOV <br /> "a N.SANJOa ST..sSTOCKTON'CA Phone (209) 468-3420 EB-0250 (11/94) <br /> (NO MAIL IS RECEIVED AT THIS AOORESS) ///J J <br />