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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: + i 3SSOU�h �}{i�/`t CACI S} PERMIT SR# <br /> Lot <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 license is in full force and effect. <br /> License #: H �5 R Q 5 Exp Date: I /S l /Z01(c <br /> Date: Contractor: l 1;nca_� da Z// ; <br /> Signature: 4t__ -"� Title:_ [ �ll7Tl(1,�7� � 1:'/�r.,� '' <br /> 10 <br /> Print Name:__Kyill'rr <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 /> 1 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:B (� Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if 1 should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall,forthwith comply with those pr 'ons. <br /> Exp. Date: Signature: -- <br /> Print Name: <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 /> aT RIZ N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 0.4 rkM , 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 /> plan dated on the front page of this application. <br /> EHD 29-01 05!09112 WELL PERMIT APP <br />