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ICANNED <br /> SaaJoeiquin County Environmental Health Services, Unit IV well Permit Aapitcatiun Supplement <br /> JOB ADDRESS. IOXOCk Le%Alr u S4L�MIT SR#:,_, , <br /> LICENSED CONTRACT ORS DECLARATION (LCD) <br /> I <br /> I hereby affirm that I am kcensed uneer the provisions of Chapter 9 (=onimercing wits £edion 7000)of Divis on ` <br /> i 3 of the Business a"ndProfessions Code and my liceffect. <br /> license is!n v, forge and a <br /> Lxense 1P: ' 0 <br /> // a_��Q Expiration Date. 10 • —31 • cZCC17 <br /> nate: <br /> 0-005 Convactor. W I LLSi Dc 6Q I FCHN 1CAL J�Q J(S_l_N z; i <br /> Signature: —1 Title: _ 6W T(Y� <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirm under penalty of perjury ane of ft following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a cefifi;aw of consent to seifansure for workers'compensation, as provided for by <br /> Section 37DD of the Letter Cede,for the Wormance of the work for which this perm![s la3ued. <br /> I have and will maintain workers'compensation insurance,as required by SseFon 3700 of the Labor Code, <br /> for the performance of the work for which this peernit is issued. My workers' compensation:iawdnce <br /> carrier and policy numbers are: <br /> Carrier. Policy Number, IS154�0 — <br /> I codify that in the peftnotance of the work ter which this permit is issued,I shalt not employ any person in I <br /> any manner so as to become subject to the werlGefa'conpensafion laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 or the Labor Code,1 snail <br /> forthwith comply with those provisions. <br /> Date: 3 l b Signature: til ��✓ l r� <br /> jPrinted Nama <br /> I <br /> i WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUi.AND SSALL SUEJECr <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANO CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> tS100,00(L),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY`S FEES.AND DAMACcS AS <br /> PRCMDSO FOR IN SECTION 7706 OF THK LABOR CODE. <br /> ! JoJaw <br /> Iti w fC.57 licensed autho.ir d rspreavniative),hateby ` <br /> to sign this San Joaquin County Well Permit Application brs my behalf, I Underetatiti this authorizaGdn is Valid for <br /> Lone(1)year and is tail ib 0te work pear,dated cm inn front bar a Uus appiicatior,. _ �_) <br /> �CTrL P.E14 <br /> DEPARTMENT USE ONLY r <br /> Application Accepted By Date �� f 1 Q ? Area Employee 1D#•J G7� 3 <br /> Grout Inspection By /45✓� r ®Date �� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed WellDepth It <br /> :O <br /> MM TS_ /��-r / � <br /> P SC Received Chec Amount Permit' <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> 43 72- 15 c, <br /> m43.o2-006,4�77t' /- sic - ;r-2- 5S4°/ <br /> M005 W ELL PUMP PERMIT <br />