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Joaquin County-Environmental Health Depat`�t <br /> 60 t?. •lain Street-Stockton CA 95202-Phone: 209-468-3420 PAYMENT <br /> RE*�EIVED <br /> APPLICATION RARI 7 2O�/, <br /> F,NVIRONNIL•'NTAL HEALTH SA-H JpAOVM 7 <br /> PERMIT TO OPERATE ���DOE kETM L <br /> EMPLOYEE HOUSING AR LABOR CAMP PA <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change or Owner Address Permit ID#: 0010982 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000344 <br /> Site Name: LIMA RANCH 39-344 Location: 13436 N THORNTON RD,LODI <br /> Operator: LIMA,JOHN P&HELEN TRUS <br /> Mailiur Address: 13436 N THORNTON RD, LODI CA 95242 Facility Phone#:(209)334-5422 <br /> Legal Owner: LIMA,JOHN P&HELEN TRUST - New Owner? ❑Yes [] No <br /> Ow uce Address: 13436 N THORNTON RD,LODI CA 95242 Owner Phone#•(209)463-1218 <br /> Community facilities Provided byCamp: Community Kitchen? ❑ Yes No <br /> Nlen: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housiu Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buil lin c I"ntnlo vecs <br /> Dormitories ..... from 4/ to JAI j Crop <br /> SP Dwellings _ from _/_/ lo_/ /_- Crop <br /> Apartments <br /> Owner Owned MH/RV 'total Number of Days to be used this Calendar Year: i� to <br /> Owner Owned RR Curs Total Days Occupied by 25 or more Employees: <br /> MI L/RV Spaces <br /> N= <br /> TOTALS ], f 1 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,ifcamp will not be used this year but is intended for use in the future,Check this Bos and return this application. <br /> Fee Schedule nl <br /> f Permanent Camp Annual Permit Fet $35.00+ Number of Employees _ a$12.00 each=$ 9(.D <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Pennanent Amendment Fee $20.00+ Number of Additional Employees a $12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees cr $24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ /3,1 (>D <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> NIAKL CHECKS PAYABLE to EItD <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 ENIPLOVEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health <br /> and Safer),Coyle and Cha to 1,Subcha ter 3,Title 25,California Code of Regulations. <br /> Applicant Name 's Titley(a- �— Partnership <br /> (Please PRINT or TYPE) Ej <br /> Corporation <br /> Address al1 a Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type ChecldReceipt# Received By Account ID <br /> 131. 6 l7 0002995 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0003418 PR0515626 2765 6219-DUNCAN VVA0515595 <br /> Reoort#:7066 <br />