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— San Joaquin County Environmental Health Department <br /> WELL &B6Rwd P eRtmf 11AFf°1LgCA-M®It SUPPmEiMENTAL <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JO PERMIT SR # <br /> PERMIT SR # <br /> j — <br /> Ll����v�f����� <br /> I h Mf RPrr9RC(&q�@r��lr� f 4�c � tiR{�d10�0) of <br /> Divi iUyi3ivjf ®alifwtifiaarr l�ia sar hd' i�rt� E a�it�r Kid i� 1011 � @r� ffVect. <br /> Lic �I6s#Ise P-4 <br /> e: b' .l1 / <br /> Date: <br /> Da <br /> Signature: <br /> Sig ature: Tfi --- <br /> Print Name: <br /> Pri t Name: <br /> WORKERS' COMP SATION DECLARATION <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <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 /> I heff8v9A8� f ll��fT, R -YARiff8St�a8Prcroyf�br lD16h� IWloroWbdct�'k dorrr"Cisatimn, as <br /> �o�idrer�"fior. Ry'�ection 3700 of the Labor Code, for the performance of the work for which is <br /> —�� <br /> dfe`TI Uiejsa�q'lill maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work fo.r which th <br /> I h is e '^` sof he. <br /> ' r VA §nE pgr, p.slr� g.rance, aE' rr6�lik&bf'�ecl �6r <br /> Labor Code, f r th' e o man e _ the work for which thiss s51P_d�j <br /> Mk rs' <br /> congw 9 e a rotic numbpwid�umber <br /> Car'ri'@ftifv that in the performance of the work for :vhi6>o1hiyMtm!tktlM � I tial <br /> personin <br /> �a�nyy manner <br /> so as to become subject to the workers' ompens Pion law f California; <br /> I cet e abor�Cbtle l�h 11 f r yv��H��6b)R`f filch i p� �r4 i mf inot3�O"y ny <br /> person in, y man e� s ( � 81I b° °(irk compensation aw of Califor ia, <br /> ExDSh gre if I h become su��ect t wor e o v�si s f Section 370 of <br /> pthe La or o e, pTy�n Iu{ho <br /> Print Name: <br /> Exp. Date: Signature: - <br /> WARNING:FAILURE-: <br /> SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,ANDS ALL SUBJECT AN PLOYER TO <br /> CRIMINAL NALTIES AND CIVIL FINES UP 1 (10(I0_J� ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S EES,ANDD AGES AS PRO D OIIVVR NRRSIIE@EC DE. <br /> W RNING: FA 1�Al,QR I'MQjlf �QV QAC EMPLOYE TO ST,, <br /> �,$`Z(D�AMAGES AS PROVIDE/DDitpORpJ I'RInCTTPO _jJ7lfl,¢0'�ensE aBthoCODE.representative), <br /> f, 0 <br /> herebyAU 1 IiVK t� ( RI `5�"SRVRRG P'ERMIF APIP�IDAITK 'mit <br /> AppIicatio on my b half. I understand this authorization is valid for one year and is limited to the work <br /> I, rl-f-fi At Page -f thiSARANSA (signature of C-57 licensed authorized representat ve), <br /> hBoring Permit <br /> AI "OMMVK'on my behalf. I understand this authorization is valid for one year and is Iimited[t,QRtbepwork <br /> plan dated on the front page of this application. <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />