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"--i Joaquin County-Environmental Health Depar'- -!nt 304 E Web venue-Third rl0%W-,Stockton CA 95202-PI 209-468-3420 PAYMENT RECEIVED- APPLICATION DEC 17 2003 ENVIRONMENTAL HEALTH PERMIT TO OPERATE SAN JOAQUIN COUNTY EMPLOYEE HOUSING OR LABOR CAMP �EpN�VIIRONMENTAL E]New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar)eaDEPNT ❑Amended Permit: *Change of Orator *Change of Owner t � Q U U*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 JCamp 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 Phone#:(209)931-4397. Community F26lities Provided by Camp' Community Kitchen' 0 Yes NE] 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 from /-J_Fj to __ 1 n 4Crop CIRRI ES Dormitories from_/_/_to_/ /_Crop SF Dwellings Apartments Total Number of Days to be used this Calendar Year Owner Owned MH/RV Total Days Occupied by 25 or more Employees Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS require a Public Water System Permit. ❑ Inactive Important: In order to protect your land use status,if camp will nut be used this year but is intended for use in the future,Check this Box and return this application. v Fee Schedule ❑Permanent Camp Annual Permit Fee: $35.00 Number of Employees @ $12.00 each=$ Orchard Camp Permit Fee: $95.00=$ 9 5 _ 0 0 Transfer of Ownership: $20.00=$ ❑ Permit Amendment Fee: $20.00+ Number of Agional Employees @ $12.00 each=$_ Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ Fee must be Qrnitted with Application TOTAL FEE DUE: $ 95 . 00 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PHS-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. NG ROAD STOCKTON, CA. 95215-9730 Phone(209) 931-2664 Applicant Signature y,l Date of Application Amount Paid Date of Payment Payment Type hec eceipt# Received By Account ID 21 D3 ✓ � 0001463 LO i Facility ID Program Record ID PIE Assigned to PWS ID 0001464 0270176 2745 1522-VAN BUREN 0001462 Report#:7066.rot Application Printed:11/19/2003