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SAN JOAQUIN COUNTY • PUBLIC HEALTH S*ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit $Annual Permit For Calendar Year <br /> Ll Amended Permit ❑Multiple Years(Permanent Housing Camps only) MMID <br /> Approved <br /> • Change of Operator -Change of Owner <br /> • Change of Operator Address • Change of Owner Address• Additional Employees <br /> Please Note any Corrections or Lhmes in Fac /O cratoriOwncr In ormation directlyon this form <br /> Site Name: LIMA RANCH Location: 1343 N THORNTON RD <br /> Operator: LIMA RANCH <br /> Matting Address: 13436 N THORNTON RD,LODI CA 95242 Faciltty Phone#: 209-368-6442 <br /> Legal Owner: LIMA,JOHN P&HELEN TRUST New Owner ❑Yes JK.Nd <br /> Owner Address: 13436 N THORNTON RD,LODI CA 95242 Owner Phone#: 209-368-6442 <br /> Community Facilities Provided by Camp: Community Kitchen: 0 Yes RNo <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: <br /> Building Employees Bandies Employees <br /> Dormitories: Owner Owned N H/RV <br /> SF Dwellings +_ Owner Owned RR Can <br /> Apartments —t MH/RV Spaces <br /> - TOTAL of Both COLUMNS — <br /> Occupancy Dates: <br /> from V to%t /�/!J a Crop Total Number of Days to be used this Calendar Year <br /> —�—�— —�— — Total Days Occupied by 23 or more Employees <br /> from to Crop Note: Camps occupied by 25 or more employees for 60 or more days a year <br /> require a PmMc Water System Pernsit <br /> ❑ Inactive ( In order,to protect your land use status if capnp will not be used this year but is AsteWed for use in the jktA +r Check this Boz and return <br /> this 9PPUMMMAL <br /> Fee Schedule <br /> ❑ Permanent Camp Amloal Permit$35.00+Number of Employees $12.00 each=$ <br /> ❑ Orchard Camp Permit Fee=$95.00=5 <br /> ❑ Transfer of Ownershlp=$20.00=S <br /> EK Permit Amendment=$20.00+Number of Additional Employees @$12.00 each=$ ,`Z CD p <br /> ❑ Late Application Fee$70.00+Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE: <br /> REMIT TOTAL FEE AS CALCULATED ABOVE IN THE ENCLOSED self-addressed ENVELOPE. M4KE CHECM PAYABLE TO: PHS/EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMrr To OPERATE. Applicant agrees that this project(camp)shall <br /> be operated and maintained in accordance with the applicable provisions of the EMnOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the <br /> Health and Safety Code and Chapter 1,Subchapter 3,Title 25,CaHfornia Code ofReguladonr. <br /> Applicant Name L/.111A J?f} NC-/4 Title A44)/1'? C' srte nhip 0 Corporation <br /> (Please PRIMPor TYPE) Add ss A3113 / h Orrtfd r, I!Cci Gil ('-A Phone <br /> Applicant Signature I Date of Application <br /> Program Record ID# 200096 4ocilky ID# 003418 Account ID# 0002995 <br /> kno nt Paid Date of pnmt I ft7nent Type gwNReoeipt# Received By <br /> P ,01) Gk I <br /> Employee#: Acct Fac ID: PR#� PWS IDIS: PIE: <br /> T �A <br />