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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 8010 S.Airport Way,Stockton,CA 95206 PERMIT SR# <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#: 906899 Exp Date: 11/30/2016 <br /> Date: <br /> 7/1/2014 Contractor: Penecore Drilling <br /> Signature: Title: President <br /> Print N e: Tuan Nguyen <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 /> X 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: vel Z�cf) 1nL,J,,ckoco. c Policy Number: wiyvr L ybZ�t <br /> I certify that in the performance of the work for which this permit is issued, I 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 I should become subject to workers' compensation visions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions.. <br /> Exp. Date: 161 L I `f Signature: <br /> Print Name: uan Nguyen <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 /> w ATTORNEY'S„F.F.ES,.AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> `”` " i4CTT� 1ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Tuan Nguyen (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) Luis Mercado , 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 05109/12 WELL PERMIT APP <br />