Laserfiche WebLink
r.. .Nor <br /> EHD 2MI 07/20/10 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: [OS-0 ;5( 7D1R1-- 0,Jt7 PERMIT SIR# <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 the Business and Professions Code and my license is In full force and effect. <br /> License#: ISS(.,0 Exp Date: t0- S1- Zn t2. <br /> Date: -( -20 L __ Contractor: STC- 4KOL LP SE(CVIC6S 1"10— <br /> Signature: <br /> AIC .Signature: 1 Title: &)UAL_trY1rlC7 (ntDtVIDuAL_ <br /> Print Name: t.FFREy e, -BA;tl-E_X <br /> WORKERS' COMPENSATION 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 /> X 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: JAI SQ/Z,'0C6C�LAtPANI/4e- TstC Policy Number: 92I6(3-7 <br /> siTA TE-, C-,F -P . <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, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. - <br /> Exp. Date: �` j -2o f'Z-- Signature: <br /> Print Name: EA^1 N E N oMS�)t <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SU13JECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100.00%IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> THWION F �t OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> > 7 ` (signature of C-57 licensed authorized representative), <br /> h authorize(print name) to <br /> sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this authorization <br /> Is valid for one year and is limited to the work plan dated.on the front page of this application. <br /> EHD2MI 07MIO <br /> WELL PERMR APP <br />