Delaware Health and Social Services Division of Public Health Environmental Health Field Services Kent County Phone: 302-744-1220 Fax:302-739-1957 APPLICATION FOR RENEWAL OF A PERMIT TO OPERATE MIGRATORY AGRICULTURAL LABOR HOUSING CAMPS & FIELD SANITATION This application must be completed for each NEW Migratory Agricultural Labor Housing Camp and Field Sanitation Facility, and for RENEWAL of the annual permit of existing Camps and Facilities. Complete all information requested and return to the address below at least 30 days prior to operating. If there are any questions regarding this form, call 302-744-1220. PLEASE PRINT OR TYPE. INCOMPLETE APPLICATIONS MAY BE RETURNED. Environmental Health Field Services – Kent County Thomas Collins Building 540 S. DuPont Highway, Suite 5 Dover, DE 19901 OPERATOR NAME: _____________________________________________________________________________ NAME OF CAMP: _______________________________________________________________________________ MAILING ADDRESS OF CAMP: ____________________________________________________________________ ______________________________________________________________________________________________ PHONE NUMBER: ______________________ EMERGENCY PHONE NUMBER: ___________________________ DESIGNATED CONTACT PERSON: ________________________________________________________________ TYPE PERMIT REQUESTED: _____HOUSING CAMP _____FIELD SANITATION (HAND LABOR) LOCATION OF FACILITY: _________________________________________________________________________ (Each location requires a separate application - duplicate as necessary) REQUESTED CAPACITY DATE OF ARRIVAL DATE OF DEPARTURE ______________________ _______________________ ______________________ CROP(S) HARVESTED: __________________________________________________________________________ REMARKS: ____________________________________________________________________________________ In accordance with the "Regulations Governing the Sanitation of Migratory Agricultural Labor Housing Camps and Field Sanitation," adopted under Title 16 Delaware Code, Chapter 1, Section 122(g), I, the undersigned hereby make application for permit to operate a Migratory Agricultural Labor Camp or Field Sanitation Facility Printed Name of Applicant _____________________________________________ Title/Position ______________________ Signature of Applicant _______________________________________________ Date __________________ DO NOT WRITE BELOW THIS LINE - FOR REGULATORY AGENCY USE ONLY RECOMMENDED FOR: ANNUAL______ PROVISIONAL______ CAPACITY______ ______________________________________ __________________ (Signature of Program Manager) (Date) ______________________________________ __________________ (Signature of Program Administrator) (Date) PERMIT #_________ DATE ISSUED:________ TYPE (Check): ANNUAL_____ PROVISIONAL_____ Doc. # 35-05-20/06/12/12 ENVIRONMENTAL HEALTH FIELD SERVICES – KENT COUNTY THOMAS COLLINS BUILDING 540 S. DUPONT HIGHWAY, SUITE 5 DOVER, DELAWARE 19901