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PAYMENT Sa laquin County-Environmental Health Departs. <br /> 18l E.} �Iton Avenue-Stockton CA 95205-Phone: 2093420 <br /> RECEIVED <br /> OCT 2 4 20 APPLICATION <br /> SAN JOAOUIN COUNTY i:]\IRO,,MENTAL HEALTH <br /> ENVIRONMENTAL PERMIT TO OPERATE <br /> HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp []Conditional Permit ❑ Multiple l ears(Permanent/lousing Camps only) Annual Permit for Calendar I earr�0 <br /> ❑Amended Permit: -Change of Operator *Change of Owner <br /> -Change of Operator Address "Change ofOwner Address Permit ID It: 0010982 <br /> "Additional Emplovees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly an this form. EH tD#• 39000344 <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 8 HELEN TRUST New Owner? ❑Yes ❑ No <br /> 0%nerAddress: 13436 N THORNTON RD, LODI CA 95242 Owner Phone-14?209)334-6d22Fxt: - <br /> Community Facilities Provided by Camp: l ommunity Kitchen? ❑ Yes No <br /> Men: blumberof Toilets NumberofShowers NumberofLavatories <br /> VN omen: Number of Toilets Number of Showers Number of lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Building En 13101Ce5 <br /> Dormitories from QL/�/ Rf _/,}L/__2Q_q Crop <br /> SF Dwellings 15 to from _/_/_to_/_/_ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3(45, <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: Q <br /> MH/RV Spaces Nsl[ <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:portant: In order to protect your land use status,if camp will not be used this year but is intended Intent in the future,Check this Dox and minor this application <br /> 4S'.c--3 Fee Schedule <br /> Permanent Camp Annual Permit Fet $3y60+ Number ofEmployees @$tj:tf0 each=$ IDJ`—. OD <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee S20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ LateAppliration1m _. $70.00+ _ __Numberof Emploueec. _ -a1S24-Meach=A. <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 15D. <br /> W <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 or 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 Safely Code and Ch I,Subchspter3 Title 25,California Code ofReguladons. TVCl l l c� <br /> Applicant Name �, -. (1`YY1 inn Title ` v�>°.(' �,Partnership <br /> (Please PRINT or TYPE) ❑Corporation' / <br /> Address L&Ak 591a Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> �' 0002995 iv t3 � t - <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003418 PRO515626 2765 6219-DUNCAN WA0515595 <br /> Recon 9 7066 Application Printed:10/14/2016 <br />