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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> c, Cash\e �- W , NokAr,p <br /> JOB ADDRESS: _ - - S �ectS Stkn, 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 licenf s iiss/inn fill force and effect. <br /> License#: C57-720904 Exp Date: <br /> Date: i / Contractor: V&W� pDrilling — <br /> Signature: 4' Title: <br /> e <br /> Karli troin <br /> Print Name: <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 /> compensatian insuran arner and policy numbers are: / n <br /> Carrier: � ) Policy Number: l(�0d ( —�T�r I <br /> I certify that in the performance of the work for which this permit is issue hall not emplo any <br /> person in any manner so as to become subject to the workers' com ensati n law of C Ifor <br /> and agree that if I should become subject to workers' compensation ovisio s of Secti 3700 f <br /> the Labor ode, I hall forthwith comply with those pro ' ions. <br /> Exp. Date: l Signature: 4Z&lk J�� <br /> Print Name: w� <br /> WARNING:FAI "CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, SHALL SUBJECT AN OYER TO <br /> C INAL PE LTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> A TORNEY'S F ES,AND AMA ES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ORIZATI N FO OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> Raynold Kablanow <br /> hereby authQonehalf. <br /> t nam , to sign this San Joaquin County Well 8� Boring Permit <br /> Application 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 05/09/12 WELL PERMIT APP <br />