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Joaquin County-Environmental Health Depat it f=,-^-�� ;,;"r l 304 E Weber Avenue-Thud Floor-Stockton CA 95202-Phone: 209-468-3420 (J APPLICATION ENVIRONMENTAL HEALTH SAN J0,1 QUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year Q00-7 ❑Amended Permit:. *Change of Operator 'Change of Owner *change of operator Address *change of Owner Address 'Additional Employees Permit ID#: 0001462 Please Note any Corrections or Changes in Facility/Operator Information directly on thi, Camp ID#: 39000176 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? ❑Yes ❑ No Owner Address: 13959 E FANNING RD,STOCKTON CA 9521.5 Owner Phone#.(209)931-4392 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from ( // ;/QZ to ,//,5 /O7 Crop C SF Dwellings from —/—/—to_/ / Crop Apartments Owner Owned ME/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: ME/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days is a year Require a PUBLIC WATER SYSTEM Permit [I 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 Permit Fee $35.00+ Number of Employees @ S 12.00 each=$ E] Orchard Camp Permit Fee $95.00=$ .00 ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ qs.,--kj Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD 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 Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name �y Yit� � Title 4UG vt'r Partnership (Please PRINT or TYPE) ❑Corporation Address ��39�q I rin PIA,17QSaI ' Phone Applicant Signature ) u Date of Application /ah.10-ta Amount Paid Date of Payment Payment Type ec eceipt# Received By Account ID a ✓ Iq' 2 U 0001463 Facility ID Program Record ID PIE Assigned to PWS ID FA0001464 PR0270176 2745 1522-VAN BUREN N/A Report#:7066.rot Application Printed:10/23/2006 " '