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WP0038111
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4200/4300 - Liquid Waste/Water Well Permits
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WP0038111
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Entry Properties
Last modified
6/28/2018 10:40:21 AM
Creation date
6/28/2018 10:40:08 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038111
PE
4372
FACILITY_NAME
LINCOLN UNIFIED SCHOOL DISTRICT
STREET_NUMBER
6844
STREET_NAME
ALEXANDRIA
STREET_TYPE
PL
City
STOCKTON
Zip
95207
APN
09711018
ENTERED_DATE
6/28/2018
SITE_LOCATION
6844 ALEXANDRIA PL
RECEIVED_DATE
3/30/2018
P_LOCATION
01
P_DISTRICT
002
Tags
EHD - Public
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JOB ADDRESS: <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: ( ��hl4Y�' CS1 ) <br />License #: � ) 3 Ql C/ - <br />Expiration Date: <br />Signature: J Title: &(' rSl f'/1 <br />Print Name: ! Date: I ;�-) 9 • / k <br />WORKERS' OMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as <br />provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: SVP �Vm Policy #: 5 Exp. Date: C <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />�1 kA�UTHORIIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />y�.6 1_ L. wl o , hereby authorize / I (- )/ <br />Name of -21 Lice ntad—onu n R*part at— IIM Nlmeo Au1h011 d ynt <br />cm <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br />1 Lk—d A.,M,Uld Rap .... nud- <br />EHD 29.01 8.1.2017 Site Mitigation Well/Boring Permit Application <br />
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