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San Joaquin County-Environmental Health Department <br /> 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar l car 2026 <br /> ❑ Amended Permit: "Change of Operator "Change of Owner <br /> "Change of Operator Address "Change of Owner Address <br /> "Additional Employees <br /> State ID#:39-0176-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD STOCKTON <br /> Operator: GOGNA,VERNON 39-176 Email: <br /> Mailing Address: 13797 E FANNING RD,STOCKTON CA 95215 Facility Phone#: (209)9314392 <br /> Legal Owner: GOGNA,DENNIS New Owner? ❑ Yes ❑ No <br /> Owner Address: 13797 E FANNING RD,STOCKTON CA 95215 Owner Phone#: (209)603-0011 Entail: <br /> Community Facilities Provided by Cama: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: NumberofToilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this 1 ear: Occupancv Dates: <br /> Buildings Firiplovees <br /> Dormitories from / / to / / Crop <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 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 <br /> ❑ Permanent Camp Annual Permit Fee $54.00+ Number of Employees @$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ 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-addressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMTT 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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Title ❑Partnership <br /> (Please PRINTor TYPE) ❑Corporation <br /> Address Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# I Received By <br /> - - <br /> J-- <br /> Facility ID <br /> Program Record ID P/E Assigned to PWS ID <br /> FA0001464 PRO_170176 _7�� Rena LeRnc <br /> Report#:7067.rpt <br />