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San Joaquin County-Environmental Health Depart ��t RE�NED <br /> MEN <br /> 600 Main Street-Stockton CA 95202-Phone: 209 3420 <br /> NOV 2 0 2008 <br /> APPLICATION SAN JOAOUIN 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) 191 Annual Permit for Calendar Year Jpoci <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0001462 <br /> Please Note any Corrections or Changes in Facility/Operator h7formation directly on this I 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 Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from QLL/1S/ toe `L/�_/��c� Crop ChtxrfLi�, <br /> SF Dwellings from _/ / to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 61 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> 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 a $12.00 each=$ <br /> m Orchard Camp Permit Fee Number of Employees $95.00=$ J`':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 <br /> TU t AL FEE DUE$ <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 n t s � rt Title `PC 4 ni r ® Partnership <br /> (Please PRINT or TYPE) ❑1 Corporation / <br /> Address r O. o C& IQ50t-- Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/R ceipt# Received By Account ID <br /> Sock <br /> oZ 3 �Q ��� 0001463 <br /> �� �-� � � v � / <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA000146 000,L4 PR0270176 2745 1421 - N/A <br /> 7-I o �� <br /> Rep Date ►ort#:7066.rpt Application Printed:10/30/2008 <br />