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PAY/�ncA, <br /> San Joaquin County-Environmental Health Department T <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 EC <br /> _ Ao V R 11�,. <br /> APPLICATION SAN JOAQU v�Uzi <br /> ENVIRONMENTAL <br /> PERMITITOO OPERATE HEALTH p p ER��TY <br /> EMPLOYEE HOUSING OR LABOR CAMP E_j�►r <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) k'l Annual Permit for Calendar Year C� <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of 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 RANCH <br /> Mailing Address: 13436 N THORNTON RD, LODI CA 95242 Facility Phone#:(209)334-5422 <br /> Legal Owner: HAMM FAMILY TRUSTMACK&PATRICIA HAMM IRREVOCA New Owner? ❑Yes No <br /> Owner Address: 13436 N THORNTON RD,LODI CA 95242 Owner Phone#:(209)334-5422Ext: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <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: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from _/_/ to_/ / Crop <br /> SF Dwellings kD from _/ to Crop <br /> Apartments <br /> Owner Owned ME/RV i Total Number of Days to be used this Calendar Year: <br />\ Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <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: In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule Q; <br /> ® Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ Uv <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 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 EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health <br /> and Safety Code and Chapter rm <br /> bchapter 3,Title 25, ornia Code of egulattons. <br /> Applicant Name a �,(1CA-, Title _�C W � ,'Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address U 1 CAA Q9J "1 — Phone AM_51 54/P,'a.. <br /> Applicant Signature - Date of Application 3 <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 8%,aD J /J P —7 DOS <br /> 0002995 <br /> Facility ID Program Record ID PIE C�J Assigned to PWS ID <br /> FA0003418 PR0515626 2765 0034-AHMED WA0515595 <br /> r�a ° 3 1 <br /> Report#:7066 Application Printed:11/1/2023 <br />