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EHD 29-01 07120710 WELL PERMIT AFP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: U -�32 E�-,s4 �I"�'% S`�`��`'�CI 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 /> -�^ 5(31L),o i <br /> License#: T`�'6 -��� _ Exp Date: 3 �I <br /> Date:_ Ota _----- Contractor:��� �oc�l.eY•� Csl�`�'�^��` <br /> Signature. Title: <br /> a <br /> Print Name: k I+t <br /> �'�w"� U - � �`'��'� <br /> �RKERS' 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 worker:' 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 /> _ 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 becorne subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: __—__--Signature: `l� l . <br /> Print Name: <br /> WARNING=FAILURE TO SECURE <br /> PENAL 7 ES AND CAVIL FINES PUP TOT$100,000ION ,IA SHALL <br /> NDD TION TO THE COST OGE IS UNLAWFUL,AND COMPENSATION EMPLOYER TO <br /> INTEREST, <br /> CR <br /> I <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 /> L_ (signature of C-57 licensed authorized representative), <br /> a thorize �^^ ��'^<< — to <br /> hereby (print name) <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 /> WELL PERMIT APP <br /> EHD 29-07 0780110 <br />