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San Joaquin County-En,, ronmental Health Department 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) *Annual Permit for Calendar Year E]Amended Permit: *Change of Operator *Change of Owner TT *Change of Operator Address *Change of Owner Address Permit ID#• 0001462 'Additional Employees State ID#: 39-0176-EH EH ID#: 39000176 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD,STOCKTON Operator: GOGNA,DENNIS Mailing Address: 13797 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 Legal Owner: GOGNA,DENNIS New Owner? ❑Yes 14 No Owner Address: 13797 E FANNING RD,STOCKTON CA 95215 ONvner Phone#:(209)603-0011 Ext: 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 O4 �� ,�, _f �eS Dormitories from / / ' to,{IILn/!1\_/2� Crop (�1j�'�`�Q SF Dwellings from_/ / to_/ / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: I � Owner Owned RR Cars Total Days Occupied by 25 or more Employees: ,'IPAYMENT ' MH/RV Spaces Note RECEIVED TOTALS ® Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit J A N 2 5 2021 El 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. cnnl innnl nnl COUNTY Fee Schedule y,zE t0 N M E N TA L Permanent Camp Annual Permit Fee $50.00+ Number of Employees 30 @$15.00 each=$ S`' A�TfVD E PA RT M E N T ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application ��O O� TOTAL FEE DUE$ 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 ubchapter 3,Title 25 California Code of Regulations. Applicant Name Title d 1"-I 1�Q � artnership (Please PRINT or TYPE) ❑Corporation Address I q(��245 Phone r i'l—W 3-W Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Reee' ed B Account ID -q��72,v 0001463 Facility ID Program Record ID P/E (, Assigned to PWS ID FA0001464 PR0270176 2755 9819-BENIAMINE WA0515737 Report#:7066 Application Printed:11/19/2020