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San Joaquin County Environmental Health I)epi rtment <br /> WELL SL BORING PERMIT APPLICATION �' J 'f LEMENTAL <br /> JOB ADDRESS: 's"" " , " "°'a, "`°"` °A PERAIT SR# <br /> LICENSED CONTRACTORS DECLF`FATION QQD} <br /> I hereby affirm that I am licensed under the provisions of Chapter a (corTmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my li Ensit is in full force and effect. <br /> License#: Z�` t'C��.J i Exp Date: ,-` ( I CD 12-D (u <br /> Date: qks Ii Contractor. <br /> Signature: �f Title: <br /> f <br /> Print Name: <br /> WORKERS' COMPENSATION DECLAh:ATION <br /> 1 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-in- Jra for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the pei xmance of the work for which this <br /> permit is issued. <br /> I have and Will maintain workers' compensation insurance, ;.,s required by Section 3700 of the <br /> Labor Code, for the performance of the work for which Ols permit is issued. My workers' <br /> compensation insurance carrier a,nd policy numbers are: <br /> Carder.SL,k-C.. Tk-" Policy Nurc bar: <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 work)yrsCompensation law of California, <br /> and agree that if I should become subject to workers' romper sa:ioo provisions of Section 3700 of <br /> the Labor Code, i shall forthwith comply With those provisions. <br /> t2-1 � � 2o� S <br /> r: <br /> Exp. Date:... Signature: <br /> Print <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFI kf.J SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO 'HE 1:DST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 1706 OF Ili:LABOR CODE. <br /> AUT F R17fHER THAN C-57 SIGNING r1E R MIT APPLICATION <br /> 1, (signature of C-57 xmed authorized representative), <br /> r' <br /> h by oriz rintname) °°"'° ° ' '""", to sign this San Jcagn County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for ,ns .tear and is limited to the work <br /> plan dated on the front page of this application. <br /> EHE N-61 0.516011] <br /> WELL PERMIT APV <br />