My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
FIELD DOCUMENTS
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
F
>
FIELD
>
1856
>
2900 - Site Mitigation Program
>
PR0523459
>
FIELD DOCUMENTS
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
12/10/2019 9:30:07 AM
Creation date
12/10/2019 8:51:41 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0523459
PE
2959
FACILITY_ID
FA0015853
FACILITY_NAME
TYCO ELECTRONICS (FORMER)
STREET_NUMBER
1856
STREET_NAME
FIELD
STREET_TYPE
AVE
City
STOCKTON
Zip
952032037
APN
13339003
CURRENT_STATUS
01
SITE_LOCATION
1856 FIELD AVE
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
SJGOV\wng
Tags
EHD - Public
Jump to thumbnail
< previous set
next set >
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
273
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
02/22/20os 09: 10 FAX 4" euc <br /> San Joaquin County Epvironmental Health Department Unit tv Well Permit Application supplement <br /> ItIN , 1954 Flmp Ave • PERMIT SR#: 7/ 7 ,J/ <br /> JOB ADDRESS: Gl T^t s'a 9s-2e 3 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> ^z—3� Expiration Date: <br /> LicensciR <br /> zz o Contractor. <br /> Date: - <br /> Signature: « Title: <br /> – / <br /> Print name• � <br /> �( u •'^ <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to aelf-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: _lam- l ✓� Policy Number. <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: l J/ 1 Signatures <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,U00.).IN ADDITION TO <br /> FTHE OF LABOR COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR N SECTION <br /> A HOR17ATION OTHER <br /> THAN C-57 SIGNING PERMIT APPLICATION <br /> �TG.—. (signature ofC-67 licensed authorized representative), <br /> hereby au Drize(print nems) L i <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application- <br /> 8-29-021 MI <br /> EHD 29-02.001 <br /> /JiJlM <br /> a d Baia-ess CDCs) 2U? tf > Ja ISN dso :al 90 as pact <br />
The URL can be used to link to this page
Your browser does not support the video tag.