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f <br /> Y�D A_,�-2131$5 <br /> Q <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT/APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 819 N. Hunter St . , Stockton, CA PERMIT SR# 462,6--?V <br /> 95202 <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 California Business and Professions Code and my license is in full fore and effect. <br /> License#: 802334 Exp Date: [1 / 111-011 <br /> Date: I I I I Contractor: RSI Drilling <br /> Signature: 1�, Title: V;c,P_ �rP c�_�L� <br /> Print Name: � ;nc,`Q_�A 21'e <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:/ct �c cL C �Y�W Co.Policy Number: <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, Iall forthwith comply with those provisions. <br /> Exp. Date: (Z Signature: 1 <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, -DON ( ,!!�nk 61 L-) 11- (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) w1 1 1 1 am pi IDE.,q, 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 /> EHD 29-01 07/28/10 WELL PERMIT APP <br />