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, `D <br /> rTth IT EAPIRt <br /> San Joaquin County En0"VAXW�l 44*1WFWith3Ut <br /> WELL & BORING PERMIT $(?(�11 ( dl �a <br /> �ly Environment i Health Divislon <br /> L <br /> JOB ADDRESS: Z3� �G�� IMGiYI �'q fI lit ERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of tthhej California Business and Professions Code and my license is in full orce and effect. <br /> License#: I , Ex Date: -? L <br /> Date: tl � l ) Contractor: <br /> Signature:1\4,—) Title: ��S► \ <br /> Print Name: � CYWL, M <br /> WORKERS' OMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 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 ins ranarrier a d policy numbers are: <br /> Carrier: Policy Number: JJ+ <br /> I <br /> I certify that in the performance of the work for which this permit is issued, shall of employ any <br /> person in any manner so as to become subject to the workers' compen tion law of Califor <br /> and agree that if I should become subject to workers' compensation provisi ns of Section 3700 0 <br /> the La or C de, I shall forthwith comply with those provisions. <br /> Exp. Date: V Signature: Vmlo wa& f! <br /> Print Name: V �Ah� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT A EMPLOYER TO <br /> CRIMINAL PENALTIE AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEE ,AND AMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UTHORI <br /> TIO <br /> FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print e) , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />