My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
FIELD DOCUMENTS_FILE 2
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
H
>
HUNTER
>
819
>
2900 - Site Mitigation Program
>
PR0522087
>
FIELD DOCUMENTS_FILE 2
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
2/24/2020 5:35:20 PM
Creation date
2/24/2020 2:29:11 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
FileName_PostFix
FILE 2
RECORD_ID
PR0522087
PE
2960
FACILITY_ID
FA0015049
FACILITY_NAME
UNIFIRST CORP
STREET_NUMBER
819
Direction
N
STREET_NAME
HUNTER
City
STOCKTON
Zip
95202
CURRENT_STATUS
01
SITE_LOCATION
819 N HUNTER
P_LOCATION
01
QC Status
Approved
Scanner
SJGOV\sballwahn
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
151
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
San Joaquin County Environmental Health Department <br /> WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR# <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 force and effect. <br /> License#: `40(, ;6 K Exp Date: S��II1y�r3 <br /> Date: It I11,S 11)-a��� Contractor: 7�.G <br /> Signature: t 6 Title: v, <br /> Print Name:_ <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: .40 C0: d NVcAyu r 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, I shall forthwith comply with those provisions. <br /> Exp. Date: Signature: i 171 ,LL1,4, <br /> Print Name: R11\V I t')-,`1)\Vslti. <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, 1� u�--Y (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Woms-( , 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 05/09112 <br /> WELL PERMIT APP <br />
The URL can be used to link to this page
Your browser does not support the video tag.