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Joaquin County-Environmental Health Depar, t �' Yll��hf7 <br /> P A <br /> YMENT <br /> 600 1.E.Main Street-Stockton CA 95202-Phone: 209-468-3420 <br /> CEIVED <br /> MR, 13SAN 20ti <br /> WTr <br /> APPLICATION FIWRONNEWTAL <br /> ENVIRONMENTAL HEALTH HEALTH Lq PARTXIEW <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) *nnual Permit for Calendar Year <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#: 39000176 <br /> EH ID#: 39000176 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <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 ❑ No <br /> Owner Address: i3959 E FANNING RD,STOCKTON CA 952 i3 Owner Phone#:(209)93-i-4392 <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 /> s y <br /> Dormitories Buildine Employees frortV /Ie,/ 1 ,/ to V1f//�_/A Crop <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 /> Imnortant: 1n 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 Fe( $35.00+ Number of Employees @$12.00 each=$ _ <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 /> U Laic Applicaliun Fee $70.00+ 'NLanbcr of Employees ,a--.$24.00 each—$ <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 Vha ter 1,Subchapter Title 25,California Code of Regulations. <br /> Applicant Name W Title - artnership <br /> " <br /> (Please PRINT or TYPE) Corporation <br /> Address I Phone yV V I <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Chec eceipt# Received By Account ID <br /> 0001463 <br /> Facility ID Program Record ID PIE Assign T <br /> to PWS ID <br /> APlAFA0001464 PR0270176 2745 2089- WA0515737 <br /> Report#:26F).rot Applicatio P' ted:1 1/11201 2 <br />