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San Joaquin County Environmental Health Department WELL& BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: _)i} )t: ,'•1+?c' Et{`� -h ,">-Oita)=�1� L-fA- PERMIT SR# LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. License#: 7 V"46 x_ Exp Date: Z ��/ /G Date: Z Contractor:-61� / T Signature: Title: 0i/ O�PLC Print Name:-- WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) } 1 ,Tf i I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this E i permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the., I: Labor Code, for the performance of the work for which this permit is issued. My workers' I compensation insurance carrier and policy numbers are: Carrier: A--, c/ Policy Number: i I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, and agree that if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. i L31Exp. Date: Signature: s Print Name: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER;7n' , CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE. i AUT IZA14CIN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION I, (signature of C-57 licensed authorized representative`};. hereby authorize(print name) `..0-a �a It}LSU , to sign this San Joaquin County Well & Boring PerMij Application on my behalf. I understand this authorization is valid for one year and is limited to the worl<l plan dated on the front.page of this application. EH029.01 05:03/12 WELL PERMIT APP is r: z 1.