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San Joaquin County Environmental Health Department <br /> -yWELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I B`a0 lAJ C-5TC, l ly%F 2� PERMIT SR# <br /> 1 a64u 3 Ca. 85304 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licens d under the provisions of Chapter 9 (commencing With Section 7000) of <br /> Division 3 of the California <br /> \\Busin ss and Professions Code and my license i in��fuul�ll rce and effect. <br /> C V E ate: Ll <br /> 2lJ <br /> License#: p <br /> Date: "ntrocSignature: le: <br /> Print Name: f <br /> WORKERS' COMPENSATI N 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 /> I 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 /> compensat <br /> -1) <br /> sura ce ,,ler and ppoli y numbers are: <br /> Carrier. /I I/ l -U t!/�� Policy Number:go��& �S�O <br /> I certify that in the performance of the work for which this permit is iss ed, 1 s 11 not employ any <br /> person in any manner so as to become subject to the workers' cc pensation aw of California <br /> and agree that if I should become subject to workers' compensation p visions of Section 3700 of <br /> the LabolCodg, I SIT 11 forthwith comply with thoseprovis Ens./ <br /> Exp. Date: V ( Signature: dJ G <br /> Print Name: j <br /> WARNING:FAIL TO SE URE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMI AL PENA TIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTO NEY'S FE S,AND DAMAGEPROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.IHER THAN C-57 SIGNING AU H TION FOR NG PERMIT APPLICATION <br /> (sjgnature of C-57 licensed authorized representative), <br /> r <br /> hereby author <br /> ze(prl t name) Q,V tto sign this San Joaquin County Well & Boring Permit <br /> Application on y half. 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 /> EY.D 2301 WELL PERMIT PPP <br />