Laserfiche WebLink
1DEC. 19, 20061 5; 56PM 9253:PRRSONS-925-979-9781 GREGG DRILLING NO, 5103 . P. 5 04 <br /> '1006 4:1111 IORSONS-925-979-978' � N0, 5058 P. 4 <br /> Sen Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS; 3526 5LKC 4ah PERMIT SM: <br /> i <br /> LICENSED CONTRACTORS DECLARATION (LCA <br /> 1 <br /> I hereby affirm that I am lioensed under the provisions of Chapter 9(commencing with Section 7000)of Divislr�n <br /> 3 of the Business and <br /> Professions Code and my license Is in full force and effect.1 Ii <br /> License#;��P"�`-' Expiration Date: <br /> Date: oZ j— Contracto <br /> Signature: Title: <br /> Printed name: <br /> f <br /> I <br /> WORKERS'COMPENSATION 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-lnsure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. <br /> have and will maintain workers'compensation Insurance,as required by Section 3700 of the labor <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: Q 1 <br /> Carrier' Policy Number: <br /> I certify that In the performance of the work for which this permit is issued, I shall not employ any person in I <br /> any manner so as to become subject to the workers'Compensation laws of California,and agree that if I <br /> should become subject to the workers'compensati n provisions of Section 3700 of the Labor Code,i shall: r <br /> forthwith comply with those provisions. <br /> Expiration Date: _ 1�07 Signature: a <br /> Printed Name:—IkCl <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,0110.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION ROT 1 <br /> HER THAN C-57 SIGNING PERMIT APPLICATION <br /> I' (signature OfCd7 licensed authorized repmeentativV), <br /> hereby authorize(print name) Z= QA N <br /> to sign this San Joaquin County Well Permit Application on my behalf, I understand this authorization Is.YAW ton <br /> ono(1)year and is limited to the work plan dated on the!runt page Of this application. ! ' <br /> i <br /> e-29-021 MI <br /> EHD 29.02.001 <br /> G42/0a <br />