Laserfiche WebLink
96/14/2094 09:H7 2094E83 <br /> " FIFTH FLflOP, <br /> San Joaquin County Environmental Health DepartMe Unit IV Well Permit Application SupPiemerrt <br /> Wz 'r�. PERMIT SR#: <br /> J013 ADDRESS: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby aff rm that 1 am llcenleod s Cede andmyo is Chapter <br /> pte 9(commencing <br /> coce m affect. <br /> with Section 7000)of Division <br /> 3 of the Business and Prole <br /> Expiration Date' <br /> License#:._, <br /> Date; 4 -7 Contractor: �^ <br /> signature: <br /> Printed name- <br /> W KERS' COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one of the fallowing dedsrations: (CHECK ONE) <br /> -insure for yyp <br /> 1 have and will maintain a certificate of consent In sett fof Which this permit is issued. <br /> compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for w <br /> Section 3700 of <br /> he <br /> or <br /> •L'have and Will Race of the ark for=rnpewhich this opensu is issued.as require uworkers`cornpensationtinsu a�ce a� <br /> for the performs <br /> carrier and policy numbers are: , <br /> '/� }� /�t Policy Number: <br /> Carrier. <br /> n in <br /> rmit is iEis <br /> I certify that in the <br /> performance!Of the work <br /> bB ore sUbject o the workeres comthis pe cation laws at California,and agree ghat f t al <br /> any manner so provisions of Section 3700 of the Labor Code,L ghaII <br /> should become subject to the workers'cortspensation <br /> fcrtimwith cornply with thas provisiZUre: <br /> Expiration Date: <br /> Printed Name_ 12) <br /> Rs,compENSATION GE is UNLAWFUL,AND SHALL S <br /> WARNING: <br /> TO SECURE <br /> ELRE WORKS AND CIVIL r-NLS LIP TO ONE HUNDRED THOUSAND p LARSL16.lECT <br /> AN EMPLOYER TO CRIMINAL <br /> PROV DEj,IN A 11N SEC TION 37 6 OF 7H Ft Ala PECODEiON,INTEREST,ATTORNEYS FEES,AND DAMAGES A <br /> ioo,ucciUTHORlZAT10N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature oiC-57 I' ensed author presentative) <br /> 1, <br /> hereby auth -zs print name) ?35-1)121 Q <br /> to sign this San Joaquin County Well Permit Application on my beh i understand this a,nhorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this appfioation. � a - <br /> e_24 02 f M! qw? <br /> rc s <br /> c� r <br /> E"D 2"2-041 <br /> 9�70r2t:a3 <br /> Z 'd uapTeM R.jew d9EtTD faD LC daS <br />