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tt cz+, M oaquin County-Environmental Health Depar ffignm I3( I Z^ �6011 r,.Main Street-Stockton CA 95202-Phone: 209-30o-3420 ,,hd��"" oft "� 4N 13 2012 APPLICATION ENVIRONMENT HEALTH ENVIRONMENTAL HEALTH PERMIT/SERVICES PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) ,Annual Permit for Calendar Ycarr'- ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID# 0001462 *Additional Employees State ID#: 39000176 Please Note aniv Corrections or Changes in I`acililV/Operator/rtforntation clir•c c(!t,on this form. EH ID#: 39000176 Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD, STOCKTON Operator: GOGNA,VERNON Mailing Address: 13959 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 Legal Owner: GOGNA,VERNON New Owner ❑Yes No I Owner Address: 13959 E FANNING RD, STOCKTON CA 95215 Owner Phone 4:(209)931-4392 I Community Facilities Provided by Camp: Cotnnmmity Kitchen'? ❑ Yes ❑ No Men: Number of Toilets 2 Number of Showers Z Number of Lavatories 2 Women: Number of Toilets 2. Number of Showers Z Number of Lavatories 2. (lousing Accommodations to be Utilized this Year: Occupanev Dates: Buildings Emnloyccs Dormitories from/�?/ o��'%1�/� Crop �t� �_•_ 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 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive Important: In order to protect your land use status,ifcamp 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 Fet $35.00+ Number of Employees a $12.00 each=$ ® Orchard Camp Permit Fee Number of Employees $95.00=$ t C ❑ Transfer of Ownership $20.00=$ ❑ Ponnatient Amendme;it Fee $20.00 Nu nbcr of,^,dditicral F.mployces C$1'_.00 each=$ ❑ 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)shall be operated and maintained in accordance with the applicable provisions of the EINIPLOYEE HOUSING:'LCT,Chapter 1, Part I, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name r> t-V Title Eil-Partnership (Please PRINT or TYPE) if ,/ _ .� 77`` ❑Corporation Address +C1 1 . i I VA iv>C t °�\ 06- ��Z1� Phone 2tli "'(_%S 1--Z Lc Ll Applicant Signature t �.a,tn,ra � c—t Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0001463 Facility ID Program Record ID PIE Assigned to PINS ID FA0001464 PR0270176 2745 n 2 9-SOOD WA0515737 Report#:7066.rpt i4ru a 2-22. /`I( Dated t 3t— Application Printed:10/25/2011