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WELL PERMIT APP <br /> EHD 29-o1 07120110 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 244 West Harding Way,Stockton, CA PERMIT SR# <br /> JOB ADDRESS: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of C iapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my li tense is in full force and effect. <br /> License M C57-848359 =xp Date: <br /> Date: IC e j - Contractor: 1 <br /> Signaturet� Title:_President <br /> Print Name: Robert Slagle <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•;elf-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, fc r the performance of the work for which this <br /> permit is issued. <br /> x I have and will maintain workers' compensation in! urance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for w rich this permit is issued. My workers' <br /> compensation insurance carrier and policy numbe s are: <br /> til - `t <br /> Carrier: \t � txlCA 'olicy Number. 'Al 1� <br /> I certify that in the performance of the work for whi;h this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to :he workers' compensation law of California, and <br /> agree that if I should become subject to workers' t ompensation provisions of Sectioa 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions r <br /> Exp. Date: �- " � L Signatur <br /> Print Name: Robert Slagle <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAC E IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN A 3DITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAM G�$AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> A i R OTHER THAN C-5l SIGNING PERMIT APPLICATION <br /> i, (signatt re of C-57 licensed authorized representative), <br /> 'fiereby authorize(print name) Advanced GeoEnvironmental Representatives ,to <br /> sign this San Joaquin County Well& Boring Permit Applicrtion on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated o i the front page of this application. <br /> EH02"1 07rM10 SMELL PERMIT APP <br />