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IF 'in Joaquin County-Public IIealth Serv" Environmental Health Division 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: APPLICATION ENVIRONMENTAL HEALTH J PERMIT TO OPERATE NOV 14 2000 EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only Annual Permit for Calendar Year ❑Amended Permit: *Change or Operator *Change or Owner *Change of Operator Address *Change or Owner Address *Additional Employees Permit ID#: 0001462 Please Note any Corrections or Changes in Facility/Operator Irfonnation directly 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(hancr? ❑Yes )M No Owner Address: 13959 E FANNING RD,STOCKTON CA 95215 Owner Phone#: (209)931-4392 Community Facilities Provided by Camp: Community Kitchen: Dye, 0 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: 'Does Buildings Employees fromL4_/L501to_6_/J301Crop CHERRIES SFDwellings _ from_/_/_to_/ / Crop SF Dw Apartments Total Number ofDays to be used this Calendar Year Owner Owned M H/RV Total Days Occupied by 25 or more Employees Owner Owned RR Cars MH/RV Spaces Note: 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 u§e 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=S ®X Orchard Camp Permit Fee: $95.00=S 95.00 ❑ Transfer of Ownership: $20.00=S ❑ PermitAmendment Fee: $20.00+ Number of Additional Employees @ $12.00 each=S ❑ Late Application Fee: $70.00+ Number of Employees @ $24.00 each=S Fee must be submitted with Application TOTALFEE DUE: S 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 operates' snd maintained in accordance with the applicable provisions of the EMPLOYEE HOUSINNG ACT, Chapter 1, Part 1, Division 13 of th California Health wed Safely Code and Chapter 1,Subchapter 3,Title 25,California Code of Reguladous Applicant Name VERNON GOGNA Title PARTNER ®Partnership (Please PRINT or TYPE) ❑Corporation Address 139 E. FANUNI -ROAD STOCKTON, CA. 95215-9730 Phone(209)931-2664 Applicant Signature Date of Application 12/10/00 Amount Paid Date of Payment Payment Type QR Receipt# Received By Account ID 9"5.C�) 1 7, / 0001463 Facility ID Program Record ID PIE Assigned to PWS ID 0001464 0270176 2755 5366-MEDINA 0001462 Report#:7066.rpt V t/ &W 2 oq Application Printed:11/7/00