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EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2900 - Site Mitigation Program
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PR0536710
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Last modified
7/11/2019 9:32:02 PM
Creation date
7/11/2019 4:37:46 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0536710
PE
2950
FACILITY_ID
FA0021089
FACILITY_NAME
VACANT
STREET_NUMBER
520
Direction
N
STREET_NAME
EL DORADO
STREET_TYPE
ST
City
STOCKTON
Zip
95202
APN
13906032
CURRENT_STATUS
01
SITE_LOCATION
520 N EL DORADO ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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EHD - Public
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. V 0 • <br /> EHD 29-01 07/20/10 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 520 NORTH EL DORADO STREET, 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. <br /> License #: <br /> C57-680227 Exp Date: 30 November 2013 <br /> Date: 21 December 2011 Contractor: ADVANCED GEOENVIRONMENTAL, INC <br /> Signature: Title: PRESIDENT <br /> Print Name: R ERT E. MARTY <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 /> xxxx 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: TRAVELER'S Policy Number: 3338T982 <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: 17 October 2012 Signature: <br /> Print Name: ROBERT E. MARTY <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby 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 /> EHD 29-01 07/20/10 WELL PERMIT APP <br />
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