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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1600 Durham Ferry Road, Tracy, CA PERMIT 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 the California Business and Professions Code and my license is in full force and effect. <br /> License#: 1 <br /> C57-72J904 Exp Date: <br /> Date: ontractor: V&W Drilling <br /> Signature: Title: <br /> Karli St ing <br /> Print Name: <br /> WO KERS' 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 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 wi I maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, or the performance of the work for which this permit is issued. My workers' <br /> compe satio insur arrier d policy numbers are: 1 <br /> Carrier: Policy Number:9 <br /> J <br /> I certif that the performance of t e work for which this permit ' issu shall ploy any <br /> person in y manner so as to become subject to the workers' ompen ation I w of lifornia, <br /> and agree that 'rf I should become subject to workers' compen provi ions o Section 700 of <br /> the La rCode, shall forthwith comply with thosl pro 'sio <br /> Exp. Date: Signatur <br /> Print Name: <br /> WARNING: FAILU SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHAL SUB ECT AN EMPLOYER TO <br /> CRI NAL P NALTI D CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF ENSATION, INTEREST, <br /> AT FINEY'S EE ,ANDD AGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> H RIZ TION R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> Eric Price <br /> hereby au orize(p 'nt n ) to sign this San Joaquin County Well & Boring Permit <br /> Application ehalf. 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 OSI09I12 WELL PERMIT APP <br />