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S, raquin County-Environmental Health Depart t PAYMENT' <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phon. 409-468-3420 R E CEI V E D <br /> L <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Yeats(Permanent Housing Camps only) Annual Permit for Calendar Year 00`7 <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 Information directly on thi, 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 (14/LS/0-7 to 3�0/L6/O-7 Crop C. y1t,C, <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 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 $35.00+ Number of Employees @$12.00 each=$ <br /> B] Orchard Camp Permit Fee $95.00=$ <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 /> TOTAL FEE DUES <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 Safely Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name � nt` r3o Title Partnership <br /> v�nc� ,� � <br /> �] <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address /3g5q 'lnq PA,7 cpasa, ' Phone 6?31-a�co-f <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type �:hecIeceipt# Received By Account ID <br /> I 0001463 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0001464 PR0270176 2745 1522-VAN BUREN N/A <br /> LKN_'_ /S- 8 S <br /> Report#:7066.not Application Printed:10/23/2006 <br />