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an Joaquin County-Environmental Health Dep, nent 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP E]New Camp E]Conditional Permit E] Multiple Years(Permanent Housing Camps only) Vf-grinual Permit for Calendar Year 99 ❑Amended Permit: *Change of Operator *Change of Owner *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: 13959 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 Legal Owner: GOGNA, DENNIS New Owner? ❑Yes ❑ No Owner Address: 13959 E FANNING RD, STOCKTON CA 95215 Owner Phone#:(209)603-0011 Ext: Pwfm&JT Communitv Facilities Provided by Camw Community Kitchen? ❑ Yes No RECEIVED Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories ONC �-& 2018 Housing Accommodations to be Utilized this Year: OecuRanCy Dates: SAN JOAQUIN COUNTY Buildint=s Employee s ` A /��E�NVIRO,�IMENTAL Dormitories frorr( / / �� took /1 1 Crop VIIREI�tnftb ARTMENT SF Dwellings from /_/ to_/ / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 1 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: IJ MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year L 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 a r� Permanent Camp Annual Permit Fee $50.00+ Number of Employees �51 @$15.00 each=$ �0• C)V ❑ 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 I- �, GIO 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 Chapter I,Subchapter 3,Title 25,California Code of Regulations. ^ Applicant Name r�0a y\," ( n&- Title `iTbit_ Partnership (Please PRINT or TYPE) � Q� .j,.,� ❑Corporation Address 1 - _' VCk_A %n'0-A! 9 ��2—AS Phone Applicant Signature Date of Application Amount Paid Date of Payment 0ayment Type Check/Receipt# Received By Account ID 0001463 Facility ID Program Record ID PIE L C� So Assigned to PWS ID FA0001464 PR0270176 2755 6219-DUNCAN WA0515737 Report#:7066 Application Printed:11/9/2018