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0 0 <br /> Faffirmthat <br /> Joaquin County Environmental Health Department <br /> WELL BORING PERMIT APPLICATION SUPPLEMENTAL <br /> : 1245 W Charter Way, Stockton <br /> PERMIT SR# <br /> ICENSE CONTRACTORS DECLARATION (LCD) <br /> at I am lice ed under the provisions or Chapter 9 (commencing with Section 7000) ofalifornia Bu iness and Professions Code and my license is in full force and effect.710079 <br /> Exp Date: <br /> Date: Woodward Drilling <br /> 9 <br /> Signature: <br /> Title: <br /> Print Name: CQx R <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will mainta n 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 maintai 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: LM ol np CL <br /> olicyNumber.G (1 U1'�00(1D LQ Ci R' <br /> I certify that in the perfoinance of the work for which this permit is issued, I shall not employ any <br /> person in any manner s as to become subject to the workers' compensation law of California, <br /> and agree that if I shout become subject to workers'compensation provisions of Section 3700 or <br /> the Labor Code, I shall f hwith comply with those provisions. <br /> Exp. Date: -\" \`� Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKE S'COMPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND C JIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMj GES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FO R OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authori (print name Ray old `blanow <br /> ) , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I uncle stand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of thh application. <br /> EHO3901 0&MI, <br /> WELL PERMIT WP <br />