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'1 <br /> Joaquin County-Environmental Health Depar t PAYMENT <br /> 1868 E _-nzelton Avenue-Stockton CA 95205-Phone: 2u.-468-3420 <br /> d "/ 7t197 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year ZI <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 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. <br /> 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 th(209)931-4392 <br /> Legal Owner: GOGNA, DENNIS New Owner? ❑Yes o <br /> Owner Address: 13959 E FANNING RD, STOCKTON CA 95215 Owner Phone#:(209)603-0011 Ext: <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: Occupa/nccy� Dates: t n /0 �n /� <br /> Dormitories Building Employees I ovees from V��1.'Z6/ I I tot / (h/ I Crop l/, �X <br /> SF Dwellings from _/ / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV 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 /> Im on rtant: 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 /> +57 oo Fee Schedule tS.c- 4C\G OD <br /> Permanent Camp Annual Permit Fee $35-@T+ Number of Employees @$;2.9 each=$ <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> f I I ate Application Fee $70.00+ Number of Employees Ca$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <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 3 Title 25,California Code of Regulations. <br /> Applicant Name 1)Q,1 "\5 0(A i It Title oAf partnership <br /> (Please PRINT or TYPE) !j/ _ �l [I Corporation <br /> Address 1n 1 1(�1 D v`vN q�7� Phone J(- — ::�p—00 11 <br /> Applicant Signature Date of Application 4 I <br /> Amount Paid Date of Payment 'Payment Type Check/Receipt# Received By Account ID <br /> _ 0 r/ / ` (— K —_� I ' r a—" 0001463 <br /> Facility ID t Program Record ID P/E '1 (Assigned to PWS ID <br /> FA0001464 PR0270176 2755 6219-DUNCAN WA0515737 <br /> Report# 7066 Application Printed:10/14/2016 <br />