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ft <br />Minnesota Department of Health <br />Environmental Field Services <br />717 SE Dk.,oware St . P 0 Box 3441 <br />Minnespol : Minnesota 554dp <br />612 623 53j5 <br />tication for License to Operate a <br />M :ufacttared Home Park and/or <br />eagional Camping Area i <br />PRIMARY LICENSE: $75 00 for each 50 sites or fraction thereof <br />F (first license issued to Park or Campf <br />E ANNUAL LICENSE — Year Round lover 6 months). S15.J0 for each 10 sites or fraction thereof <br />E Maximum of S450.00 <br />S — Seasonal 18 months or less) S11 _5 for each 10 sites or fraction thereof <br />i Maximum of $337 50 <br />go SEE REVERSE SIDE FOR FEE SCHEDULE, COMPLETE WORKER'S COMPENSA -" )N SECTION <br />10, ADD S:0.00 LATE PAYMENT FEE IF A -PLYING AFTER JANUARY 15 FOR ANNUAL LICENSE OR 15 DAYS AFTER OPENING <br />FOR SEASONAL OPERATION <br />MAKE CHECK PAYABLE TO: Minnesota State Treasurer <br />_ NEW LICENSE INew Parts mwt anach pat a.ecrip!wn or iris, include all wop•m !or present or h,wrs mesa 1 <br />W PrevrOua Open+w Date P,rchated <br />IIENEWAL " OWNiASHIP CHANGE <br />Up license no. wes issued for the following quantity of <br />Mobile Home Sites Independent Camp Sites Dependent Camp Sites <br />Name of Uterisee (portion. hrm or corporation! -- Taiepnons <br />[�) I 14Uj dill•. " 1. C%1�a.a tf C�c ) <br />Mohr q Adarelig Itnc+udo too coast L' <br />Z.1. set 5 A C t, <br />Fort o. Camp Trade Name <br />• � I <br />Addnma# PWO or Carp '} <br />10" EXACT LOCATlok eNa04 O!*ECTION TOi n' � f; t <br />LAie Jill ' "ka' tC.6 K a Stream ►rgn.rey Hoed <br />Townshro & t C_ , c <br />Po+t Office r k[ C' I S t e. <br />oannsM or Co�taoratton — ira Officers <br />S►.tvi GC. 1,Z1`is. SSyl2 <br />Operation: Q Year Round Seasonal (list opening data and months of operation), ►i1a� ! $ <br />No, of sites' _ Mobile Horne Some 3 f.1„ Dependent jamp si4 Independent Camp Sites <br />11"404e. Oeeendw" sees ars without sower connectoons ) <br />No. of Sites Oectrpied: Moai Home sites G. ietWent Camp Sites independent Gamy Sites <br />� kuretOM�wtures in entrel Buildiing if Provided MUMMA I SHCVWjWr_UAINALSH TNT_ <br />Women: <br />is %raU" pool Orevidepf res A no V �if Pr!mmvo Campground list number of pnvies: <br />Wow SiipOy: r nwme,paf private No. of pies with indrvtdual weter hookwpe: C <br />sausage system: j nnunlslpel private No of soles wrttt ind+viduaf sewer hook-ups: _ <br />You must subrnq plans in trip"Cate for now construction or alteration License cannot he renewed without this depertme"t's prior <br />approval for sddinonel Saes. You must submit a copy of an approval permit from the munscipaltty or county in which the perk or <br />".imp is 180 1 d or a ststtt+mtnt from that mun+cspal,ty or county that no permit is required. No license wilt be issued until sit <br />repwrWWWM haw been met_ <br />Pea �rear.eee a Sronawrre _ <br />Law t arwtent he m J ��% <br />C F T +r <br />TOTAL ; <br />.t e! lea q t <br />wr <br />