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San Joaquin County Environmental Health Department • <br /> WELL & BORiiING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1 si Laic n _-I``J.r_Trac C A PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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 its in full force and effect. <br /> License#: �n _ — —N — ----- Exp Date: 3 i (L <br /> Date: 4 — Contractor: Na, cele+ � <br /> -- -nom-h- ----�hs._-------- <br /> Signature: Title: <br /> Print Name:_ TAcQ3 G LC " "( <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 /> _ 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. rnt t� r�ltrC�n Policy Number: We 1-5'133.?0_z <br /> ---------- -- -- - <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 provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisioner - <br /> Exp. Date:_ lr (f // Signature: <br /> Print Name: - <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 /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ALIT TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> —_.. t (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)5,_Sh— � p k 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 /> EHO M-01 09091E WELL PERMIT MP <br /> • <br />