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t ` Sa, lquin County-Environmental Health Departm ?AYMENT 304 E Weber A ae-Third Floor-Stockton CA 95202-Phone. )-468-3420 r_(�c �t I U ED A-M APPLICATION J trL D ENVIRONMENTAL HEALTH // 01 PERMIT TO OPERATE /Z�3 SA JOAOUIN COUNTY EMPLOYEE HOUSING OR LABOR CAM P 'I_IC'rtEAL;H SERVICES N T;+L HEALTH DIVISION ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2 0 0 3 ❑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 I 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 LLega'Ow. er: GOGNA,VERNON New Owner? ❑Yes ❑No wner Address: 13959 E FANNING RD,STOCKTON CA 95215 Owner Phone#:(209)931-4392 Community Facilities Provided by Camp: Community Kitchen: LJ Yes NLJ 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(.__/1 A 03o-fLI-5/03Crop C.H E RR I E S 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 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 @ $12.00 each=$ ❑ Orchard Camp Permit Fee: $95.00=$ 95 . 00 nn Transfer of Ownership: $20.00=$ El Late Amendment Fee: $20.00+ Number of Additional Employees @ $12.00 each=$_ r1 Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ Fee must be Submitted with Application TOTAL FEE DUE: $ 95 . 00 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Sett-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 (063 — &0// Title PARTNER g® Partnership (Please PRINT or TYPE) ❑Corporation Address 13959 E . F ING ROAD STOCKTON, CA. 95215-9730 Phone (209) 93 1—2664 Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0001463 a oz V' !`�03C� '%c Facility ID Program Record ID PIE Assigned to PWS ID 0001464 0270176 2755 1522-VAN BUREN 0001462 Report#:7066.rot Application Printed:11/20/2002