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San Joaquin County. Environmental Health Depat#Invent <br /> WELL& BORING PERMIT AQPi.ICA'f IC?!1t SUPPLEMENTAL <br /> .ios.Al nREss PERMITSR'# <br /> LICENSED CONTRACTORS DECLARATION QC:D) <br /> I hereby affirm than am licensed under the provisions cf hapfer 9 (commencing with Section 700(}}of <br /> Division 3 of the California.BUsiriess and Professiohs Coed an;d.my ficer}se is in Rall fo:rce.and effect. <br /> License* <br /> -} Exp Date' IM�k :.. <br /> Date-. G... 74� Ccarltefor <br /> Title, •�` s <br /> .. <br /> Pfil'it Riame: <br /> WORKERS'COMPS'JSATICtN'O CLARA'1'!N <br /> #'hereby affirrrl.unties penalty of perjury one of the fo.liowin.+;I.:deoiarations::(Check:o.ne) <br /> f Have .and will maintain a. certifi'c'ate :of consent to self-insure for workers` carripeiisation, as <br /> provided for by 8ectit5.n 370(}of the Labor,Code, for the performance of th6 work for Whioh this. <br /> permit`is Issued, <br /> ! _i have and will.Maintain workers,` compensation: i:risUrance;, .as required by Section 37€30 of the <br /> Labor Coda. for the perforritance, of the work f0t which tris. perrrlit is issuei#. IwAy workers' <br /> compensation:Insurance carrier and policy number:31-Are: <br /> Catriex : <br /> Volicy.Number ( : <br /> I certify,that.in.the perrfoe"ofte of the:work for which this permit is iSSU6d,.l:shall`not employ any <br /> persciri in any.manner so as :to :becomef subject-to the workers' comperisatioil law of California, <br /> and agree that if'] should become subject to worko-5' compensation provisions'of Section 3700 cf. <br /> the:Labor Ct2d8,I shall forthwith co npfy:wlth those Drovisfons <br /> Exp.I?at@. <br /> Print..Larne - � '' <br /> WARNING:FAILURE TO SECUfEE.WCRKERS'toMP 9VSA'71QN COWER:AC9f?IS:UNLAWFUL,ANR3SHALLSIIktJECT'Ah!EMPLoYER:.TO <br /> CRltA1NAL PENALTLES.ANWMA0 p TO $100,000, IN t4>DITIEIN'"TO THE COST OF COMPENSATION,iNTERE5.T, <br /> ATTpRNEY 3 Fk'ES,.AND DPROVIDED FOR IN SEC I'!oN'370b OF TIE I fil30I2 CODE. <br /> Y - A' . <br /> PIRR THAN C 57 SIGNING PERMIT APPLICATION <br /> (signatuti 01 G-5?' ilcensed authorized representative), <br /> :#i ie 'authorize(print r3arii ) r :t ,. tosign this.San Joaquln COUrtty WeilA..Boring:Permit <br /> Application on my.behalf. I understand this authorization l;t•vafid fbr one year and.is timjted to-the work <br /> plan dated On the front.page of this-applicatioh. <br /> r:�i�;�;at a�rz8rscz <br /> Vit-L-1 PERMIT'APP <br />