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San Joaquin County Environmental Health I;epaltment <br /> WELL & BORING PERMIT APPLICATION S,IF'PI-EMENTAL <br /> JOB ADDRESS: 3138 East Main St. Stockton 1: =-lZMIT SR# <br /> LICENSED CONTRACTORS DECLP,RA,TION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 1 commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my Iic:!n3E! is in full force and effect. <br /> License#: 848359 1=xp Date: _:I 1_:10-14 <br /> Date:' -VF1 I a-T Contractor: P-11 Well Abandonment <br /> Signature: -�! = Title: Preside ,it <br /> ..... <br /> Print Name: Robert D Slagle <br /> WORKERS' COM PENSATIOIN DECLAF!X-II:>N <br /> I hereby affirm under penalty of perjury one of the following declaration 5: (check one) <br /> I have and will maintain a certificate of consent to self-insure) •br workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the perlornance of the work for which this <br /> permit is issued. <br /> have and will maintain workers' compensation insurance, :13 rE+quired by Section 3700 of the <br /> Labor Code, for the performance of the work for which tl• s pl)rmit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: nn <br /> Carrier:_ 1�{' � Policy Numl:-er: <br /> I certify that in the performance of the work for which this per-rlit is, issued, I shall not employ any <br /> person in any manner so as to become subject to the workw s' compensation law of California, <br /> and agree that if I should become subject to workers' compem-'alion provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp, Date:�� .1 l Signatures <br /> Print Name:_ ►:: �, ,L <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE:IS UNLAWFIII.,AN)SHALL SUR JEC AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO IHI: (:OST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF IHI:LABOR CODE. <br /> AUTHORI TIO�R-OTHER THAN C-57 SIGNING 1:E R,VIIT APPLICATION <br /> i <br /> (signature of C-57 I ,ensed authorized representative), <br /> `Kereb authorize M c ae A Berrington <br /> y (print name) , to sign this San Jo:3q iir County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for t:na Irear and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29.01 05/09/12 WELL PERMIT APP <br />