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` EH029-01 07/20/10 <br /> WELL PERMR APP <br /> QGGQ�1� <br /> San Joaquin County Envlronme a Healt epartment <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I JOB ADDRESS: 320 South Stockton Avenue PERMIT SR# �� 3 g7 <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 Business and Professions Code and my license is in full force and effect. <br /> License#: CS7 Exp Date: /Z-3:: �/ ? <br /> r <br /> Date: // l Contractor: �rpga 06, <br /> i <br /> Signature: Title: <br /> Print Name: ir� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: Policy Number. .L/ 67K217>1<-/ <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any I <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the i <br /> Labor Code, I shall forthwith comply with those provisions. i <br /> I <br /> Exp. Date:_ 6-- (�( Z Signature: <br /> Print Name:1LL �U/I� 1 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO i <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, i <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> i <br /> NATIO R OTHER THAN C-57 SIGNING PERMIT APPLICATION i <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Rinayak ACharya ' <br /> ,to <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this authorization i <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> c <br /> Ipt <br /> EH029-01 0720!10 <br /> WELL PERMIT APP I <br /> t{t <br /> f <br />