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Applications Will Be Processed When Submitted Properly Completed. Be e ro Sign The Application. OFFICE USE ONLY For Calendar Year Area Multiple Years(Permanent Housing Camps) Conditio I err�itJ n "i: Date Approved I.D. NO, t IlY APPLICATION Permit (For Non-Transferable, Revocable, Suspendable) Date Mailed ENVIRONMENTAL HEALTH PERMIT New Existing L ! 1 TO OPERATE Change EMPLOYEE HOUSING OR LABOR CAMP FEE IS DUE WITH APPLICATION Location 13955 E Fanning Road— Stockton, Ca 95215 Operator VERNON GOGNA Address 13959 E Fanning Rd. Stockton, Ca 95215 Telephone No. 209-931-4392 Legal Owner VERNON G GOGNA New Owner Yes XX No Address 13959 E Fanning Rd Stockton, Ca 95215 Telephone No. No. Employees Housed 30 Occupancy Dates From 4-23-96 To 6-30-96 Crop CHERRIES From To Crop Total Number Days Used This Calendar Year Inactive— IMPORTANT. If this camp is not to be used this year but is intended for use in the future, this application is to be returned marked "Inactive" too protect your land use status. ti V. Da FEE SCHEDULE Permanent Camps Annual Permit $35.00 + No. Employees @ $12.00 each = $ PAYMEN —XX_Orchard Camps$95.00 Transfer of Ownership $20.00 y o. r Amend Permit$20.00 Additional Employees ® $12.00 each = $ d 1996 MAR 2 Late Application Penalty Fee $70.00 + Employees @ $24.00 each = $ PUBLIC HEALTH SERVICES Applicant agrees to all necessary inspections incident to issuance of permit to operate. ENVIRONMENTAL HEALTH DIVISION Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Employee Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. Please remit in the enclosed self-ad sed a velope togeth r with applicable fee. DO NOT SEND CASH. � / Date 3-14-96 Signed X Title FOR DEPARTMENT USE ONLY Fees Is Due: ❑ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑July 1&Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES P O Box 2009 STOCKTON,CA 95201 OFFICE ADDRESS EH-0250(11/88) 445 N.SAN JOAOUIN ST.,STOCKTON,CA (NO MAIL IS RECEIVED AT THIS ADDRESS)