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SAN JOAQUIN COUNTY a PUBLIC HEALTH I1rVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E WEBER AVENUE a THIRD FLOOR a STOCKTON CA 95202 a 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 /> U Amended Permit [I Multiple Years(Permanent flousln8 Camps Esau W Approved <br /> • Change of operator *Change of Owner site Mauled: <br /> • Change of operator Address • Change of owner Address ersak# <br /> • Additional Employees lamp ID# <br /> Please Note any Correcdow or Changes In F"XtylOperatorlOwier In ornlatlon directly on this form <br /> Site Name: LIMA RANCH Location: 1343 N THORNTON RD <br /> Operator. LIMA RANCH <br /> Mailing Address: 13436 N THORNTON RD,LODI CA 95242 Faclift Phone#: 209-368-6442 <br /> Legal Owner: LIMA,JOHN P&HELEN TRUST ------ — - -— -- -- �Wrw Owner ❑Yes - <br /> Owner Address: 13436 N THORNTON RD,LODI CA 95242 Owner Phone#: 209-368-6442 <br /> Community Facilities Provided by Camp: Community Kitchen: [J Yes RNo -75/-67X-2-' <br /> Men: Number of Tollels Number of Showers Number of Lavatorles <br /> Women: Number of Toilets Number of Showers Number of Irvatorles <br /> Ilousing Accommodations to be Utlldaed this Year: <br /> Buil,#AW Employees (hares Owned MH/RV Bpndirss Emalor <br /> Dormitories: ee+ <br /> Dones: <br /> itori s: --� Owner Owned RR Can --MH/RV S -- <br /> Aparimenr■ —� aces <br /> P _ <br /> -- - -- TOTAL.Of BOth C-OI.ITNfNS 1 4 <br /> Occupancy Dates: <br /> from lLl to /--z U el Crop Total Number of Days to be used this Calendar Year <br /> Caep Total Days Occupied by 11 or more Employees O� <br /> — —— ——— — Note: Cwtps occuped by 23 or snare emidowes for 60 or mom dyaw <br /> require a PkbJtc Waley System Perot& <br /> Inactive jam: In order to protect your land use status tfca*p mil not be used 11us year but is iwteadeid jw x"1A tke fhtwr Check this Bou and return <br /> this appucatiaw. <br /> Fee Schedule <br /> ❑ Permanent Camp Armual Permit$35.00+Number of Fmpleyees _ $12.00 each–S <br /> Orchard Camp Permit Fee=$95.00-S <br /> ❑ Transfer of Ownership=$20.00-S <br /> Permit Amendment_$20.00+Number of Additlorral Fmpleyees CO)$12.00 each_$ ,,Z e 7 •d C7 <br /> ❑ Late Application Fee$70.00-f Number of Employees (a$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE: � <br /> REMIT TOTAL FEE AS CALCULATED ABOVE IN THE ENCLOSED self-addressed ENVELOPE. MUW CHECKSPAY.4eLETo. PIIS/EHD <br /> Applicant agrees to all necessary Inspections Incident to Issuance of a PERMIT To OPERATE. Applicant agrees that this project(camp)shall <br /> be operated and maintained In accordance with the applicable provislous of the EMPLOYER HOUWNG ACT,Chapter 1,Part 1,Division 13 of the <br /> Heath anti Safety Coda and Chapter 1,Suukba/pter 3,Title 25,CaHfornta Code ofRegukdom. <br /> L <br /> Applicant Name /111A )M AV u4 Title /�GtJ}?E'-�- l .e+aer+iy ❑C"Toradoa <br /> (Please Pk1lJf or 7YPE) A ..3 3(0. )h Ornfo Yl JZc� -041 C Phone 3-3 Y <br /> Applicant Signature Add s n, fl,, Date of Application Aa /61 "J y <br /> Program Record Record ID# 280096 ac0lty ID# 003418 Account ID# 0002995 <br /> Arnot"Pald papa of t# Ramhred <br /> Bf <br /> Employee 0 [ Acd R Fac lD: PR it. PWS M. PIE: <br />