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l Sa uaquin County-Environmental Health Departmk PAY N!",E N 1 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 20 468-3420 R ECE IVEQ APPLICATION ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) IM Annual Permit for Calendar Year 2006 ❑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 this 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 95215 Owner Phorc#.(203)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 Housinz Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories from 4 /15 / 06 to 6 /15 06 Crop Cher r i PS SF Dwellings from /_/ to_/ / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑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 Fe $35.00+ Number of Employees @$12.00 each=$ Orchard Camp Permit Fee $95.00=$ 95.00 ❑ 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 (w,,$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 95.00 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 Dennis Gogna Title Partner Partnership (Please PRINT or TYPE) ❑Corporation Address 13959 E. FqnniW Road Stockt n Ca. 95215-9730 Phone (209)931-2664 Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Reeeipt# Received By Account ID o o , / k,�� c J ` 0001463 �2 2 U S l/ N Facility ID Program Record ID PIE Assigned to PWS ID FA0001464 PR0270176 2745 1522-VAN BUREN N/A Report#:7066.rpt � / / (V v Application Printed:11/16/2005