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San Joaquin County-Public Health Services PAYMENT <br /> Environmental Health Division 'EIS' CU <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 Pro a e- •.�.�.� <br /> �ZI7lIL <br /> APPLICATION SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH WALIC HFAITH SERVICES <br /> PERMIT TO OPERATE F:!Vli?)N AFNUJ HEAI Ill NVISION <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) )(0 Annual Permit for Calendar Year 7n(1? <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees Permit ID#: 0001462 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this <br /> 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 /> New Owner? ❑Yes ❑No <br /> Legal Owner: GOGNA,VERNON <br /> Owner Address: 13959 E FANNING RD,STOCKTON CA 95215 Owner Phone#:(209)931-4392 <br /> Community Facilities Provided by Camp: Community Kitchen: YesN <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 /> Buildutes Employees from4,—ddd02.t6--Y.:Z/Q2crop BERRIES <br /> from_/_/_to_/_/_Crop <br /> Dormitories <br /> SF Dwellings Total Number of Days to be used this Calendar Year_ <br /> Apartments <br /> Owner Owned MH/RV Total Days Occupied by 25 or more Employees_ <br /> Note: <br /> Owner Owned RR Cars <br /> MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year <br /> TOTALS 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 /> E]Permanent Camp Annual Permit Fee: $35.00+ Number f Employees— <br /> Orchard Camp Permit Fee: $12 $95.00=S <br /> ED Transfer of Ownership: $20.00=S <br /> Permit Amendment Fee: $20.00+ Number of A Tonal Employees $12.00 each=$— <br /> ❑ $24.00 each=S <br /> Late Application Fee: $70.00+ Number of Employees <br /> Fee must be tQi mitted with Appiication TOTAL FEE DUE: S 95 Dn <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PHS-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 Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> � <br /> Title PARTNER Partnership <br /> Applicant Name ' VERNON GOGNA ❑Corporation <br /> (Please PRINT or TYPE) 20 9)931-2 664 <br /> Address 13959 E ) FANNING O STOCKTON, CA. 95215-9730 Phone <br /> Date of Application 2 QA/—U <br /> Applicant Signature <br /> Amount Paid Date of Payment Payment Type Check/Recelpt# Received By <br /> AccountlD <br /> 0001463 <br /> PWS <br /> PIE Assigned to ID <br /> Facility ID Program Record ID 0001462 <br /> 0001464 0270176 2755 1522-VAN BUREN <br /> Application Printed:11/19/01 <br /> Report#:7066.rot <br />