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PAYMENT <br /> RECEIVED n Joaquin County-Environmental Health Depa.—.t`tlt <br /> 18681✓.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> FEB 0 5 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL APPLICATION <br /> HEALTH DEPARTMENT ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP 1� Q <br /> E]New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) % Annual Permit for Calendar Year.9 1i J <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ED#• 0001462 <br /> *Additional Employees <br /> State ID#: 39-0176-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000176 <br /> Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD, STOCKTON <br /> Operator: GOGNA, DENNIS <br /> Mailing Address: 13959 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 <br /> Legal Owner: GOGNA, DENNIS New Owner? ❑Yes ❑ No <br /> OwncrAddress: 13959 E FANNING RD, STOCKTON CA. 95215 n.%„i�, I'l,nne#:(209)603-0011Ext: <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 /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employee s <br /> Dormitories from 0q-/-2 / Iff-to w//11 / (� Crop l��4U('n <br /> SF Dwellings from _/_/ to_/ ! Crop <br /> Apartments I '"f'"� <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 1 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: Zj�, <br /> Iv H/RV Spaces to <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 /> Im Dortant: 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 500- DD <br /> �. Permanent Camp Annual Permit Fee $50.00+ Number of Employees _ @$15.00 each=$ `"�V <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application �-y� <br /> TOTAL FEE DUE$ 500.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 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 1,Subchapter ,Title 25,California Code of Regulations. <br /> Applicant Name Q,hr�\�jo��� Title 1'� Partnership <br /> (Please PRINT orTYPE) T _ ❑ Corporation <br /> ��.,/ n �— <br /> Address � 'l ` � ������ Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 5 CoC -- a Z 0 S l g G IL— S A t 0001463 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0001464 PR0270176 2755 6219-DUNCAN WA0515737 <br /> Report#:7066 Application Printed:1 012 3/2 01 7 <br />