Laserfiche WebLink
5..Ioaquin County-Environmental Health Departnl!'# <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) nnual Permit for Calendar Year 4Q <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0010982 <br /> *Additional Employees <br /> State ID#: <br /> EH ID#: 39000344 <br /> Please Note an},Corrections or Changes in Facility'Operator Information directly on this form. <br /> Site Name: LIMA RANCH 39-344 Location: 134 -- <br /> Operator: Lima Ranch ,l�-O�01 <br /> Mailing Address: 13436 N THORNTON RD, LODI CA 95242 Facility Ph( <br /> �� <br /> Legal Owner: LIMA,JOHN P&HELEN TRUST c'-5-iZ,,— <br /> 1..� <br /> 0"ner Address: 13436 N THORNTON RD,LODI CA 95242 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes Da No <br /> Men: Number of Toilets Number of Showers Number 01 r.av aa....,,,, _ <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> HousinE Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories from DA-/A/"to 11/2/ Crop (0a- <br /> SF Dwellings C� from _/_/ to_/_I Crop <br /> Apartments <br /> Owner Owned MH/RV r Total Number of Days tQ be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: ��- <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Important: In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fec $35.00+ Number of Employees -7 @$12.00 each=$ ?A - )y <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE$ y cc <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1, Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 2.11,California Code of Regulations. <br /> Applicant Name �Q 0, YVIl Title �(��k���� Partnership <br /> (Please PRINT or TYPE) LJ <br /> Corporation <br /> Address 3 —�� Phone -55 LI - ��- <br /> Applicant Signature L Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0002995 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003418 PRO515626 2765 6219-DUNCAN WA0515595 <br /> Report#:7066 Application Printed:10/13/2015 <br />