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WELL PERMIT APP <br /> EHE 2M1 07120/10 <br /> 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 Business and Professions Code and my license is in full force and effect. <br /> License#: l _Exp Date: IT)I )\ � L - <br /> Date: Contractor: A' <br /> Title: ' <br /> Signature: <br /> Print Name: <br /> WORKERS' COMPENSATICIN 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 elf-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 irr urance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for v.4iich this permit is issued. My workers' <br /> compensation insurance carrier and policy num are: t <br /> Carrier; 1 -- olicy Number: <br /> I certify that in the performance of the work for whi h this permit is issued, I shall not employ any <br /> person in any manner so as to become subject t4 1 he workers'compensation law of California,and <br /> agree that if I should become subject to workers' ' mpensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: <br /> �2 �, \�. Signature::.� <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERA E Is UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO$100,000,IN/ DITION TD THE COST OF COMPENSAMON,INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN S` CTION 5708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (signat-J re of C-57 licensed authorized representative), <br /> hereby authorize(print name) r I' to <br /> sign this San Joaquin County Well&Boring Permit.Applic-tion 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 /> APP <br /> END29-05 07M10 vufll AEaNrsr <br />