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San.,.,aquin County-Environmental Health Departme. RECEIVED 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 MAY 18 2015 APPLICATION ENVIRONMENTAL.HEALTH ENVIRONMENTAL HEALTH PERMIT/SERVICES PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) �- nnual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0001462 *Additional Employees State ID#: 39-0176-EH EH ID#: 39000176 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD, STOCKTON Operator: GOGNA, DENNIS Mailing Address: 13959 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 Legal Owner: GOGNA, DENNIS New Owner? ❑Yes ❑ No Owner Address: 13959 E FANNING RD, STOCKTON CA 95215 Owner Phone it:(209)603-0011 Ext: Community Facilities Provided by Camn: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occunancv Dates: Buildima Emnlovees Dormitories from cM/s/_&to 2 N I J/ (� Crop SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 more days in a year Require a PUBLIC WATERATER SYSTEM Permit ❑Inactive kul2pr an : 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. Fee Schedule �( Permanent Camp Annual Permit Fe( $35.00+ Number of Employees _ a $12.00 each=$ Orchard Camp Permit Fee Number of Employees _�y��./595.00=$ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees rr $12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees a.$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUES Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shal a operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3 Title 25,California Code of Regulations. Applicant Name )oVXIrk l l2CAYA Ul, Title 0/-1 Ey-Rer••mership (Please PRINT or TYPE) p p�� ❑Corporation Address �j�� .YLt1� �C t �1(l� L 1 Phoned )r __ Applicant Signature �yvy.w Date of Application 1(O I Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0001463 Facility ID Program Record ID P/E Assigned to PWS ID FA0001464 PR0270176 2755 2089-SOOD WA0515737 Application Printed:10/15/2014 Report#:7066