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Joaquin County-Environmental Health Depar t PAYMENT <br /> 600 e_Main Street-Stockton CA 95202-Phone: 209-4o8-3420 RECEIVED <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH ggtE+Joan courrrY <br /> M <br /> ENVIROhENTAt <br /> - <br /> PERMIT TO OPERATE 14ALlri oEPARTIOF-Kr <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Years V <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,VERNON <br /> Mailing Address: 13959 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 <br /> Legal Owner: GOGNA,VERNON New Owner? ❑Yes <br /> Owner Address: 13959 E FANNING RD,STOCKTON CA 95215 Owner Phone#:(209)931-4392 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes '1@�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 /> Buildin2s Employees �,( +,, i /' <br /> Dormitories from v I/�J/ q to OIG'/1)/4 Crop � koo` <br /> SF Dwellings from _/_/_to—/ / Crop <br /> Apartments <br /> 'lwner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> ,wner 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 <br /> Permanent Camp Annual Permit Fet $35.00+ Number of Employees S @$12.00 each=$ 0. t <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 a $12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees cr $24.00 each=$ <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 and <br /> Safety Code and Chapter chapter 3,Title 25 California Code of Regulations. p <br /> LZ <br /> Applicant Name rA—/ Title ) )!J-Rertnership <br /> (Please PRINT or TYPE) <br /> �. El Corporation <br /> Address �! 1 J 1 2-1 Phone (oU3-�! 1 <br /> Applicant Signature Date of Application t l <br /> Amount Paid Date of Payment Payment Type hec eceipt# Received By Account ID <br /> 96-- <br /> _ tI ) 93 )/ <br /> C) LE 0001463 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0001464 PR0270176 —2745 ' 2089 SOOD WA0515737 <br /> Report#:7066 Application Printed:10/17/2013 <br />