My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
SR0069023
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
C
>
CHURCH
>
800
>
4200/4300 - Liquid Waste/Water Well Permits
>
SR0069023
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
9/9/2019 3:42:43 PM
Creation date
9/9/2019 3:29:23 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0069023
PE
2905
FACILITY_NAME
DOPACO
STREET_NUMBER
800
Direction
W
STREET_NAME
CHURCH
STREET_TYPE
ST
City
STOCKTON
Zip
95205
APN
14523004
ENTERED_DATE
2/10/2014 12:00:00 AM
SITE_LOCATION
800 W CHURCH ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
TSok
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
2
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
JA* w ; fj � <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ()1Jl) w� 1,�(�1 — aJIT PERMIT SR# <br /> LICENSED CONTRACTORS ALARATION (LCD <br /> ) <br /> I hereby affum that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of thhe+ Ca4omia Business and Professions Code and my license is in full force and effect. <br /> License#: Exp Date: <br /> Date: Contractor: <br /> Signature: Title: UV_01" O,�aaFY <br /> Print Name: /"/-u1715,:/ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby&t- y of perjury one of the following declarations: (check one) <br /> _xI raw o www oo�4 maintain a certificate of consent to self-insure for workers' compensation, as <br /> ovided tx 6on 3700 of the Labor Code, for the .performance of the work for which this <br /> I ►v++o wxi a& Asintain workers' compensation insurance, as required by Section 3700 of the <br /> Lem+ :txla; ^-iw me performance of the work for which this permit Is Issued. My workers' <br /> ct,r •r� <br /> -. <br /> , . ,rance carrier and policy numbers are: �/ <br /> Carrier/i,y/__0' Policy Number. /Vlnl/0101"��P/ <br /> performance of the work for which this permit Is issued, I shall not employ any J <br /> ps^xrr rt st-<. miner so as to become subject to the workers' compensation law of California, <br /> arra atlee raw t should become subject to workers'compensation provisions of Section 3700 of <br /> Vw Labor Cr+*. shall forthwith comply with those provisions. <br /> Ex . Date P Signature: -� <br /> Print Name: C�1/'6C <br /> WARNING:FA0_LJgl TO f WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> C A%W%+4L PGbv,,INS AND CIVIL FINES UP TO:100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST,_ <br /> ATTOAMEYS FVJ,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> T ZA FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, �'�� (signature of C-57 licensed authorized representative), k <br /> hereby authorize(prin!name) , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization Is valid for one year and is limited to the work <br /> pian dated on the front page of this application. <br /> :Floe'.-Oi 05/0112 WELL PERMIT AP11 <br /> r, <br />
The URL can be used to link to this page
Your browser does not support the video tag.