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WELL PERMIT APP <br /> EHD 29-01 07/20/10 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 55 E Saks+own Sf- CA , LSL01 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 Business and Professions Code and my license is in full force and effect. <br /> License #: 'A—,L `�C.,ri Exp Date: )�)i' I <br /> Date: Contractor: <br /> I / <br /> Signature: Title: l i" - <br /> Print Name: f �_k( , <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: auk- 1-t ^1 <, Policy Number: `)�J 1 1 I 1 <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, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Signature: <br /> I <br /> Print Namei'Oct n LUej -1 _,l zM <br /> MPLOYER <br /> WARNING: FAILURE TO SECURE <br /> PENALTIES ES AND CIVIL FINES UPRS'COM PE S O$1100,000,IN ADDITION TO THE COST OF COMPENSATION,ATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN INTEREST, <br /> TO <br /> INTER ST, <br /> CR <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 /> 1, <br /> (w-1 )( (signature of C-57 licensed authorized representative), <br /> I <br /> hereby authorize (print name) F n/v I g o N I„+c rna rorty( Core- , to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> WELL PERMIT APP <br /> EHD 2901 07020/10 <br />