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S. oaquin County-Environmental Health Depart. 1868E.'ONazelton Avenue-Stockton CA 95205-Phone: 209-468- YMENT RECEIVED APPLICATION 2 ENVIRONMENTAL HEALTH DECCl• 6 ��J PERMIT TO OPERATE SAN JOAQUIN CO EMPLOYEE HOUSING OR LABOR CAMP LINTY ENVIRONMEN 0 ❑New Camp ❑Conditional Permit El Multiple Years(Permanent Housing Camps only) nneal PerLyp{eadaXeg E]Amended Permit: *Change of Operator *Change of Owner PPP''' n U� AAR � _ *Change of Operator Address *Change of Owner Address Permit ID#: 0001462 *Additional Employees State ID#: 39-0176-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000176 Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD,STOCKTON Operator: GOGNA, DENNIS Mailing Address: 13797 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 Legal Owner: GOGNA, DENNIS New Owner? ❑Yes ❑ No OwnerAddress: 13797 E FANNING RD,STOCKTON CA 95215 Owner Phone#:(209)603-0011 Ext: Community Facilities Provided by Camp: Community Kitchen? ❑ Yes 14 No yLr- Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this bear: Occunancv Dates: Buildimrs I:mplo%ccs Dormitories from/a/7,0 to 0V/ K/ !" Crop 0w fie%e-cj. SF Dwellings from / / to_/ / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: �f l Owner Owned RR Cars Total Days Occupied by 25 or more Employees: �j o\ ME/RV Spaces Note TOTALS r� Camps occupied by 25 or more Employees for 60 or more days in a year (V ® 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 e Do Permanent Camp Annual Permit Fee $50.00+ Number of Employees wD 30 @$15.00 each=$ : . ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application S� W TOTAL FEE DUE$ Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to 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 Cha ter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name YA G-)911 n&, Title 7&y'yIly_ 9knnership (Please PRINT or TYPE) [:1C?o�poration Address ��q :�dn�i�(lq 4 � C/� �i Phone 201— eU 3_-C11 Applicant Signature Date of Application Amount Paid Date of Payment (� 1Payment Type hec�kk//`Receipt# Received By Account ID 0001463 Facility ID Program Record ID P/E Assigned to / PWS ID FA0001464 PR0270176 2755 9819-BENIAMINE WA0515737 Report#.7066 Application Printed:11/13/2019