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-�AN JOAQUIN COUNTY • PUBLIC HEALTH ICES <br /> • ENVIRONMENTAL HEALTH DIVISION <br /> : 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTR 3 y <br /> PERMIT TO OPERATE <br /> EMPLOYEEHOUSING CAMP <br /> ❑New Camp ❑Conditional Permit 4 'Annual Permit For Calendar Year <br /> ❑Amosided Permit ❑Mample Yam"(permanent Heading Camps MOW) Out&Approved <br /> • Change of Operator *Change of owner we Msied: <br /> • Change of Operator Address • Change of Owner Address sink# <br /> • Additional Employees Camp ID# <br /> Please Note any Correcdods or Chmiga In F /O eralorlOwnar hyWmeAlon directly on this farm <br /> Site Name: LIMA RANCH Location: 1343(N THORNTON RD <br /> Operator. LIMA RANCH <br /> Mailing Address: 13436 N THORNTON RD,LODI CA 95242 Facility Phone#: 209-368.6442 <br /> Legal Owner—_ LIMA,JOHN P&HELEN TRUST O'lew Owner 0 Ya N <br /> Owner Address: 13436 N"1`HORNTON RD,LOD1 CA 95242 Owner Phone#: 209-368-6442 <br /> Community Facilities Provided by Camp: Community x chen: 0 Yes KNo <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Stowers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: <br /> Baildhaat Emeiovee: �4lplfefi $�� <br /> Dormitories: Owner Owned MH/RV <br /> SF Dwellings Owner Owned RR Can <br /> Apartments TT MIMV Spaces <br /> TOTAL of Both CoI.UMNs�� f <br /> Occupancy Dates: <br /> from ��to �� ��/� Crop Total Number of Days to be used this Calendar Year <br /> from to <br /> Cmp Total Days Occupied by 25 or mom Employees <br /> —— — Nom: Camps occupied by 13 orseare emplaNees for 60 srsrevr A*ra yew <br /> require a Pabdfe Wa r,S,pteas Perndt <br /> ❑ .Inactive In order to protect your land use status if can p will not be used this year but isWended jLr use,to 1k*_4shw 0mck this Binz and return <br /> this NPPUasritssa <br /> Fee Schedule <br /> Permanent Camp Annual Permit$35.00+Number of Employees $12.00 each Z1,3, Q v <br /> ❑ Orchard Camp Permit Fee=$95.00=S <br /> JG� ; ,...,,,�fer or ygnerhip=$Z0.00=S <br /> Q Permit Amendment=$20.00+Number of Additions) a __ �?s51 MrJ)(14each=$ • o U <br /> ❑ Late Application Fee$70.00+Number of Employees L$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE: r ,0 S <br /> REMIT TOTAL FEE As CALCULATED ABOVE IN THE BNaZosBD Sell--addressed ENVELOPE. M4AE CVErmPAYARLE To. PHS/EHD <br /> Applicant agrees to all necessary Inspections incident to issuance of a PxRmrr To OPERATE. Applicant agrees that this project(camp)shall <br /> be operated and maintained In accordance with the applicable provisions of the EMPLOYss Houma ACT,Chapter 1,Part L Division 13 of the <br /> Heidi and Safety Code and Chapter 1,Sabcheow 3,Title M Ca4fonda Coda ofReguhtdow. <br /> Applicant Name L//'114 l?/4 Title �_'Gfi j"7�•Y C pasb,.,Mip 0 Cw?ettition <br /> (Please PRINPor TYPE) Addtrss .,1�f l h Ur1 rid)-► 1,_J e i CA Phone i'�Ly <br /> Applicant Signature %�/C�G l�L� lt4 - to of Application //4/— <br /> Program <br /> /GProgram Record ID# 20"% A tucnity ED# 003418 Account 1D# 0002995 <br /> Amount Paid Date of t payment T Clletlt # Raeelved By <br /> \ _ 3o '? <br /> Employee fF: Acct 0.. � Fec 1D: PR#� - I PYYS IDd� a 7'S- <br /> 1----- <br /> .. _. __ — -- <br />