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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> JAN 16 2024 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp E]Conditional Permit [:] Multiple Years(Permanent Housing Camps only) Permit for Calendar Year W� <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID N: 0001462 <br /> *Additional Employees <br /> State ID#: 39-0176-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000176 <br /> Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD,STOCKTON <br /> Operator: GOGNA, DENNIS <br /> Mailing Address: 13797 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 <br /> Legal Owner: GOGNA, DENNIS New Owner? ❑Yes Y f0 <br /> OwnerAddress: 13797 E FANNING RD, STOCKTON CA 95215 Owner Phone#:(209)603-0011 Ext: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ YesLP- <br /> No <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 /> Buildines I;mnlovecs � ^—� �1� ©� KI <br /> �1,� <br /> Dormitories from /!'�/ / to_/ !=i}��1 Crop <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: J U <br /> Owner Owned RR Cars 4 Total Days Occupied by 25 or more Employees: S <br /> MH/RV Spaces /F� <br /> Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> L. 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 ��p1 <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$17.00 each=$ �/•00 <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ / <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to 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 /> Applicant Name n(, Title partnership <br /> (Please PRINT or TYPE) <br /> Corporation <br /> AddressC�{JCO(` S I� Phone <br /> Applicant Signature ate of Application 1 <br /> Amount Paid Date of Payment Payment Type Ch Receipt# Received By Account ID <br /> 1 k D 0001463 <br /> � 4 MuA&— —ni <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0001464 PR0270176 2755 3611 -GIRARD] WA0515737 <br /> Report#:7066 A I io 20 <br /> a pp c t n Printed:11/1/ 3 2 <br />