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oaquin County-Environmental Health Depa. P'AYI EN r <br /> 1868 E.1-lazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 RECEIVED <br /> APPLICATION SAN JO 2 <br /> ENVIRONMENTAL HEALTH AQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTME <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Ugnnual 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#: 39-0176-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000176 <br /> Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD,STOCKTON <br /> Operator: GOGNA, DENNIS <br /> Mailing Address: 13797 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 <br /> Legal Owner: GOGNA, DENNIS New Owner? ❑Yes ❑ No <br /> Owner Address: 13797 E FANNING RD,STOCKTON CA 95215 Owner Phone#;(209)603-0011Ext: <br /> Community Facilities Provided by Camn: 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 /> Buildines Employee s v <br /> Dormitories from(9 /2 0 /�to 10 l(.:�/.2a. 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: `t C1 <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 Fee $50.00+ Number of Employees @$15.00 each=$ C l' <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application `(l�0f� <br /> TOTAL FEE DUE$_ �v . 00 <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 �Q �jn1i rvi Title n�11''� r i-artnership <br /> (Please PRINT or TYPE) / �A El corporation <br /> Address 1201/1 1hnlnal Q Sfve,I�, l �� I�ZI�� Phone 2✓ 1'�Q(�3'�1+ <br /> Applicant Signature Date of Application 1v( <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> S M7 0001463 <br /> Facility ID �> Program Record ID P/E J Assigned to PWS ID <br /> FA0001464 PR0270176 2755 3611 -GIRARDI WA0515737 <br /> Report#:7066 Application Printed:12/2/2021 <br />