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PAYMENT <br /> S aquin County-Environmental Health Departtr RECEIVED <br /> 600 �in Street-Stockton CA 95202-Phone: 209-4L 420 <br /> NOV 4 7.009 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) 0 Annual Permit for Calendar Year c�§ — <br /> ❑Amended Permit: *Change of Operator *Change of Owner Py <br /> *Change of Operator Address *Change of Owner Addr O <br /> *Additional Employees <br /> Permit ID#: 0001462 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this <br /> Camp ID#: 39000176 <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: 13959 E FANNING RD,STOCKTON CA 95215 Owner Phone#:(209)931-4392 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets 5 Number of Showers 2- Number of Lavatories s <br /> Women: Number of Toilets -3 Number of Showers Z. Number of Lavatories 3 <br /> Housin2 Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildiniss Employees <br /> Dormitories fromoy IL5 �J/o to(��/1/ g Crop �12I S <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 or more Employees for 60 more days in a year <br /> Requiree a PUBLIC WATER SYSTEM <br /> 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( $35.00+ Number of Employees @ S12.00 each=$ <br /> Orchard Camp Permit Fee Number of Employees $95.00=$ (*5.00 <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application n <br /> TOTAL FEE DUE$ Rom, QO <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 /> anti Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name nnt� �� Title 64lntr Partnership <br /> (Please PRINT or TYPE) / ❑Corporation <br /> Address I <br /> ` 1`J a l Phone'2W <br /> Applicant Signature L <br /> Date of Application //63jy <br /> Amount Paid Date of Payment Payment Type Check/ ceipt# Received By Account ID <br /> -4 95'. C) Ii � i <br /> � /- � l t7o l t' 0001463 <br /> Facility ID Program Record ID PIE / Assigned to PWS ID <br /> FA0001464 PR0270176 2745 2089-SOOD WA0515737 <br /> Report#:7066.rot ��C� 2 5 7 Application Printe64/2009 <br />