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S raquin County-Environmental Health Departs PAYMENT 600 L Main Street-Stockton CA 95202-Phone: 209-4bo-3420 RECEIVED 'nn ( APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT ENVIRONMENTAL H HEALTH DEPARTMENT PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMPOI ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual 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#• 39000176 EH ID#: 39000176 Please Note anv 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,VERNON Mailing Address: 13959 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 Legal Owner: GOGNA,VERNON New Owner Y ❑Yes ❑ No Owner Address: 13959 E FANNING RD,STOCKTON CA 95215 Owner Phone#:(209)931-4392 Community Facilities Provided by Camp: Community Kitchen'? ❑ Yes No t Men: Number of Toilets Z Number of Showers Number of Lavatories Z Women: Number of Toilets Number of Showers Number of Lavatories `L dousing Accommodations to be Utilized this Year: Occupancv Dates: Buildines Emplovees Dormitories from�I / � /�) to /I J/gl I Crop /1f hV L SF Dwellings from / / to_/_I Crop Apartments Owner Owned MI I/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,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 Pennit Fe( $35.00+ Number of Employees a $12.00 each=$ Orchard Camp Permit Fee Number of Employees $95.00=$ G� •Co ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees cr $12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees « $24.00 each=$ Fee must be submitted with Application (� TOTAL FEE DUE S Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EliD 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 EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health and Safety Corte and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. � Applicant Name 1 nY\AS (6)( nLl Title ��r ,r E41'artnership (Please PRINT or TYPE) _ Corporation Address ��ZI� Phone - -2 Applicant Signature , Date of Application Amount Paid Date of Payment Payment Type Check/ ceipt# Received By Account ID /�� L� /�Z!� D / �•�i��S �� 0001463 Facility ID Program Record ID P//EE Assigned to PWS ID FA0001464 PR0270176 2745 2089-SOOD WA0515737 Report#:7066.rot Application Printed:11/2/2010