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EHD 20-01 OWMID WELL PERMF APP <br /> San Joaquin County Environmental Health Department <br /> WELL S BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 833 East 8th Street, Stockton, CA <br /> JOB ADDRESS: 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 Business and Professions Code and my license is in full force and effect. <br /> License#: 906899 _ Exp Date: 11/30/11 <br /> Date: 10/28/11 Contractor. Penecore Drilling <br /> Signature: Title: CEO - --- <br /> Print Name: Tuan NgL60 <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 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 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:_____State Fund _—_---_ Policy Number: 541-0000731-11 <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: 8/1/12 __------_-_—____-- Signature: _ <br /> Print Name: Tu Nguyen <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,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 /> TH RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> here y authors (print name) ArCadls , to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. 1 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 /> F40291)1 DL2090 WFLL PLRMI1 APP <br />