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P <br /> San Joaquin County-Environmental E CL�VIE,) <br /> lealth Department RE Y,c, T <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> Nov 2 a <br /> APPLICATION SAN )OQQUI <br /> ENVIRONMENTAL HEALTH NETE 1 RON""IENTUNTy <br /> EMPLOYEE HOUSING OR LPERMIT TO A AL LABOR CAMP F1 OEP- R <br /> ❑New Camp []Conditional Permit ❑ Multiple 1'ears(Permanent housing Camps only) Annual Permit for Calendar Year <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 Fnc•ilitr'Operator Information clirec•11v 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 TRUST/JACK&PATRICIA HAMM IRREVOCA New Owner 7 ❑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 Numbcr of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Ilous)ne Accommodations to be Utilized this Year: Occunancv Dates: <br /> Buildines Employees <br /> Iktrmitories from _/_/ to_/_/ Crop <br /> SI:Dwellings c' �D from _ /__/_----to ___!_ / Crop <br /> Apartments <br /> (honer Owned MH/RV 1 Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: Ch <br /> MH/RV Spaces 1vOli <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,tfeamp will not be used this year but is intended for use in th uture,Chee is Box and return this application. <br /> ch <br /> Fee Schedule # " PdN <br /> Permanent Camp Annual Permit Fec 550.00+ Number o ployces (]�n(a$17.00(cat=S 1 l l <br /> ❑ Transfer of Ownership ftmp4ttrs i�2-02� ' S2?AO=S <br /> El PermanentAmcndmcn 525.00+ Numtxr ofAdditional Employees a$17.00 each=S <br /> ❑ Late Application Fee $100.00+ Number of Employees !n S34.00 each=S <br /> Fee must be submitted with Application I <br /> "I"Ol:al.FEE DUE:S � 1No •L>LI <br /> Remit TOTAL FEE as CALCULNI"ED ABOVE in the ENCLOSED Sclf-adressed Envelope <br /> MAKE CHECKS PAYABLE to EIID <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 /> andSafet}•Code and Chapter 1,Subchapter 3,Title 25,qqbrnia Code of egulalionc. <br /> Applicant Name L,m C� L1 1 � Title C LL ,��_ Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 1 �,� Phone �- <br /> Applicant Signature — �r Date of Application ) C 3 <br /> Amount Paid Date of Payment �Payment Type Check/Recelpt# Received By Account ID <br /> 0002995 <br /> Fn= <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003418 PR0515626 2765 0034-AHMED WA0515595 <br /> Report#:7066 Application Printed:11/1/2023 <br />