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San <br /> uin <br /> LLS niocl;ajgai ink uvt ��nl�r(omo�FW4�lt � Sl ��09MAent <br /> WELL0RINGr'�ERMIT AWRTAY6§ C F WWAkAL <br /> JOB ADDRESS: I i " l Zti , 1,P.�.�., R ( S_k, �h , �1 P <br /> JOB ADDRESS: <br /> V2Ta%1MffftJ?0, <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 ( o mencin with <br /> %Aont <br /> Qftds V3a6filthL-tbatifbati'� I iG®els I Pr I@moi@�f t°b e° r{d�1fl� s 4s� I�"w �Q�O/�®�) f <br /> Division 3 of the California Business and Professions Code and my license Is In u I o ce a ect. <br /> License #: _� �; j S Exp Date: <br /> License #: Exp Da e: <br /> Date: Contractor: <br /> Date: Contractor: <br /> Signature: Title: C <br /> Signature: Title: <br /> Print Name: <br /> Print Name: <br /> COMPENSATION DECLARATION <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I herebly Rffirm under. ena.1 of perjury.one of the following declarations: (check one) <br /> ave an wil��mairt aln a cer�lficate of consent to self-insure for workers' compensation, as <br /> °M� cf�OetiTler�ital�iti�iOQa °cfe �i �°rO ���isRftt � �oefk Il�labatil�, s <br /> rove e or Section 3700 of the Labor Code, for the performance of the work for which t1lis <br /> �Gl K4`la4dW4aintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code for the. erformance pf the wor ti�rri 11 �r4po Sgr4'��L� ei8SH9dSe(M 6n�W--6f t e <br /> �br��IRs i `M4 rl�I� r�?'��a Tp8R i�r ers�afre: , <br /> Labor Cod for the pe ormance o t e wor or which this permit is issued. My work rs <br /> C§4 n{ ti�i44un?ge cg:[1 end-I? lily n 'n oEtimber: <br /> �+,., pM A''. {, � <br /> I CMf�at In the 'performance of+hc ,n,nrlr for y iich t0Vel Illll IJi E <br /> ued, I shall nut employ a[ly <br /> person in any manner so as to become subject to the workers' co ensati n la, f CNabe rt�ettta#til� kr ��iega�f jf��t\fPCrIOfgR gh&6n 6pg i1 5si��t °� ._Lino ny <br /> thpdxsbar i0odeyy Iralaalih�rl9�viils do*ygg1M a�6giArAeorkers compensa Ion aw o or ia, <br /> and agree a If I should become subject to workers' compe tion provisions of Section 370 of <br /> Exp. Dat ghe I abbe bljs all forthwith coSip�q &#hose_provis <br /> Exp. Date: Prin6ure: <br /> ARNING: FAILURE TO SECURE WORKERS'COMPENSATI ,Qr✓ g UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP�/ITCT$${ 00, IN Abut II ATION, INTEREST, <br /> WARNING: AILURE TO SECURE WORKAND ERS COMPENSATI�NI�ORI<CGE �SD �I� F�1�BI �QIR�rtL SUBJECT AN EMPLOYEF TO <br /> �c, I TIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTER ST, <br /> A`d�, ���NF�,�uI����P�c��@.bac{e7rMN�fCrov�d�Rf1��TL��t!CD�TION <br /> I, T(OAM,ffe59f S�iG��l��1�' t PrA '$����►9Ff lVe), <br /> ereby,authoriz print name y fZ �-t . , to sign this SanJoaquinCounty Well & BoringPermit <br /> dplication on my hahalf l � nderstan� this authefizaJr8pjtVaeficPtoCone liceyeansed aedd as lhm�tegdo the workati e), <br /> Idd�Mlh�l� �Olii �4�1i5 apnlir�+inn , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I . Inder-stand thus allthOFmzatmon ms valid fnr nne year -and-is limited to the work <br /> E`­"' <br /> H 29�)A`91 ited on the front page of this application. `NELLPERMIT APP <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />