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iNm',a3=i�:.p,7z:�rasuee'u:�.eesc.:,,.c..:va,�.::ss:.v uwr�c.�mzq:N"&,FC:zHBc�S1ti'.�5© <br /> Fthatl <br /> an Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> g ��y E /A1Pi`Le 8,,p - 5tdc_..k 7 (,+PERM IT SR# <br /> q Say.)' <br /> ICENSED CONTRACTORS DECLARATION (LCD) <br /> JOB <br /> at I am licensed under the provisions of Chapter 9 (commencingwith Section 7000) of <br /> alifornia Business and Professions Code and my license is in full force and effect. <br /> 7 Y ��T Exp Date: <br /> iDate: Contractor; p/',//rdz <br /> Signature (! -7.■_ Title:- <br /> Print <br /> itle:-Print Name:� �✓ �/q/f�� <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-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._&-.arm/ Policy Number: /O �/�D/ <br /> I certify that In the performance of the work for which this permit Is Issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that If I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith Comply with those provislo <br /> Exp. Date: ?(-w I Signature: /� � 1 <br /> Print Name•_ c i//r/ PG/Anoc- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSA71ON COVERAGE 16 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATrORNEY'S FEES,AND DAMAGES AS PROVIDED FOR W SECTION 3706 OF THE LABOR CODE. . . <br /> LIT I N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i' (signature of C•57 licensed authorized representative), <br /> hereby authorize(print name) , to sign this San Joaquin County well S Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work i <br /> plan dated on the front page of this application. <br /> I <br /> EHp.t9410Y09/12 <br /> ' WELL PERMIT APP <br /> j <br /> II <br /> r f <br />