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Joaquin County-Environmental Health Depar ,t ffignm <br /> 60(ft.Main Street-Stockton CA 95202-Phone: 209-468'-3420 <br /> , AN132012 <br /> APPLICATION ENVIRONMENT HEALTH <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP / <br /> ❑New Camp E]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) VAnnual Permit for Calendar Yea"21V <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID N: 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 K No <br /> Owner Address: 13959 E FANNING RD,STOCKTON CA 95215 Owner Phone#:(209)931-4392 <br /> Communitv 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 /> Housins Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employee s /I,,,, � <br /> Dormitories from/1 1A2"fo 10(a1��12d1_ Crop 'W' \e <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 /> ME/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 Fe( $35.00+ Number of Employees @$12.00 each=$ _ <br /> ® Orchard Camp Permit Fee Number of Employees $95.00=$ S Qb <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.001- Number of Additional Employees cr $12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ QS <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 �enYl.iSr�� � Title % 1,Q,+� -Partnership <br /> (Please PRINT or TYPE) -PLCorporation <br /> Address e ' n►,i i✓1C 'R,(' Jd&I C`A- j��� PhoneAI-2AAcq <br /> Applicant Signature t 1���. '�r 2 Date of Application — �'12 <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> V ^ 0001463 <br /> 2 l <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0001464 PR0270176 2745 2 9-SOOD WA0515737 <br /> Report#:7066.rot Date I 3a I2 Application Printed:10/25/2011 <br />