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San Joaquin County Environmental Health )(p; rtment <br /> WELL & BORING PERMIT APPL CATION ; J :)F LEMENTAL <br /> JOB ADDRESS: 515 West Charter WayER'nlr SR # <br /> LICENSED CONTRACTORS DECL/ F /,TION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter c ((01 imencing with Section 7000) of <br /> Division 3 of the California Business and Professions Cody and my li :�rls:� is in full force and effect. <br /> License#: rl�—� I Cq Exp Date: <br /> Date: tf t,� ! (j—Ls <br /> ��Contractor. Uf•_L—1- � � <br /> Signature: - -- �,� ; � <br /> � Title: <br /> Print Name: �r�, �; � C.>>�( ol 1 Q <br /> WORKERS' COMPENSATION DECLAI ATION <br /> I hereby affirm under penalty of perjury one of the followinc declaratic s (::heck one) <br /> I have and will maintain a certificate of consent to self-in ire for workers' compensation. as <br /> provided for by Section 3700 of the Labor Code, for the pe "Dirr ince of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance. s n:quired by Section 3700 of the <br /> Labor Code. for the performance of the work fDr which t 'is permit is issued. My workers' <br /> compensation insurance carrier and policy number; are. <br /> Carrier: � 1__ -• <br /> Policy Numl>,Er: <br /> I certify that in the performance of the work for which this perrii i:: issued. I shall not employ any <br /> person in any manner so as to become subject to the work ­s' r:ompensation law of California, <br /> and agree that if I should become subject to workers' comper : a:ion provisions of Section 3700 of <br /> the Labor Code, I shall forthwith Comply with those provisions. ,. <br /> /--��-' <br /> Exp. Date: �('� ► �� t�5 v�) Signature: <br /> Print Name: -� ` ' �iCi �r <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWF _, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ,ADDITION TO 'H_ :'OST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF H:LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 :3IGNING T F MIT APPLICATION <br /> (signature of C-57 ;E m:ed authorized representative), <br /> hereby authorize (print name William Little <br /> ) to sign this San Jc:q,ri I County Well 8 Boring Permit <br /> Application on my behalf. I understand this authorization is valid for n? 'dear and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 05101/15 <br /> WELL PERMIT APP <br />