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WELL PERMIT APP <br /> EHD 29-01 07/20/10 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 308 S. El Dorado, Stockton 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. 1, <br /> License#: ��'���S� Exp Date: K\(A '-?:6 4% <br /> 1)tkq <br /> Date: Contractor: W vIry\ awndon �Y '►" <br /> Signature: Title: <br /> Print Name: Y , ,-- <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:E\( -t `-1" Policy Number: <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'ccmpensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> S <br /> Exp. Date' S ` Signature:_ <br /> Print Name:_ ,'�P� • �1C�c�1'(� <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 /> AUTHORIZATI THER THAN C.57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereb ori print name) Daniel Villanueva 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 /> EHD 29-01 07/20/10 WELL PERMIT APP <br />