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oaquin County-Environmental Health Depart, PAYMENT 1 <br /> 1868 E. ,�f zelton Avenue-Stockton CA 95205-Phone: 209-478-3420 RECENED_'l <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH -.Qu IN couwry <br /> NMIDUAL <br /> PERMIT TO OPERATE .a.RTMExT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) *Annual Permit for Calendar Year 2 015 <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 any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: LIMA RANCH 39-344 Location: 13436 N THORNTON RD,LODI <br /> Operator: Lima Ranch <br /> Mailing Address: 13436 N THORNTON RD, LODI CA 95242 Facility Phone#:(209)334-5422 <br /> Legal Owner: LIMA,JOHN P&HELEN TRUST New Owner? ❑Yes V No <br /> Owner Address: 13436 N THORNTON RD,LODI CA 95242 Owner Phone#:(209)334-5422Ext: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes Z No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildin2 Employees <br /> Dormitories from / / to/ Crop <br /> SF Dwellings from _/ / to /_/ Crop <br /> Arm <br /> Owner Owned MH//RV Total Number of Days to 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 (p <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ <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 <br /> TOTAL FEE DUE$ <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 25,California CAde of Regulations aYpy Y`'. <br /> Applicant Name i yyk. — f C, , pti, .Y �'nP�'/"' Vpartnership <br /> (Please PRINT or TYPE) Corporation <br /> Address 13N r Phone 33 V <br /> Applicant Signature Date of Application f L <br /> Amount Paid Date of Payment Payment Type Chec eceipt# Received By Account ID <br /> �� � �� , � 1 ✓ 0002995 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003418 PR0515626 2765 6219-DUNCAN WA0515595 <br /> Report#:7066 tO(070 O d 1 DL e Ce f 'dpd( �' Application Printed 10/15/2014 <br /> 61-0t70-�497OS/ <br />