New

Renewal

Amended

State I.D. No. FOR CALENDAR YEAR Date of Application

• FEE IS DUE WITH APPLICATION - NOT SUBJECT TO REFUND

1.Camp Name:

Camp Location:

2. Camp Operator: Phone:

• • • • (Street Address/P.O. Box #) (City) (State) (ZIP)

4. Legal Owner: Phone:

• • • • (Street Address/P.O. Box #) (City) (State) (ZIP)

6. Dates of proposed occupancy: to

COMMUNITY FACILITIES: Community Kitchen: Yes No Mess Hall: Yes No

Men: No. of toilets: No. of showers: No. of lavatories:

Woman: No. of toilets: No. of showers: No. of lavatories:

HOUSING FACILITIES: No. of Dormitories: No. of Family Units:

7. Housing capacity (Number of employees not housed in recreational vehicles or mobilehomes) :

8. (a) Number of employees housed in recreational vehicles or mobilehomes being provided by employer

(b) Number of spaces being provided for mobilehomes or recreational vehicles which are owned by employees:

9. TOTAL of lines 7 + 8(a) + 8(b) . . . . . . .......................................................

ANNUAL FEES:

Application Fee: $35.00

Capacity (line 9 x $12.00):

TOTAL FEE

AMENDED PERMIT FEES:

Transfer/Change Fee: $20.00

Additional Capacity (Increase of line 9 x $12.00):

TOTAL FEE

Applicant agrees to all necessary inspections incident to issuance of a permit to operate. Applicant agrees that this project shall be operated and maintained in accordance with the applicable provisions of Division 13, Part 1, Chapter 1, of the Health and Safety Code and Title 25, California Administrative Code, Chapter 1, Subchapter 3. Applicant agrees that he or his agent will accept service of any legal notice or process at his address of record.

Date: Signed: Title:

• DEPARTMENT USE ONLY

Approved by: Date: