Laserfiche WebLink
04/27/2007 11:31 91663851�"_j CA5 ADEDRILLINGnPAGE 03/0 01 <br /> AD r, 27. 2007 11 ;04AM r,_,anced Geotnv l ronmenta i Y !yU �y.� ! <br /> San Joaquin COM"ty Environmental Health Department linit IV Well Permit Application Supplement <br /> JOB ADDRESS; C PERMIT SP-6:_ <br /> LICENSED CONTRACTORS DECLARATION (LCD, <br /> I hereby affirm that 1 am Iloensed under the provisions of Cfrap r g(commencing Wth Section 7000)of Division <br /> 3 of the Susiinesss and Professions Code and my license Is in fL II force and effect. r� <br /> License#: 1 -Expiration 38W ✓ <br /> Daate; I Contraotar. Gl G ri I l vt <br /> Signature' Tltte' r. PY- �.L� <br /> Ej <br /> Printed name; <br /> WORKERO' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following de lar-ations: (CHECK ONE) <br /> I have and will maintain a cer"cate of consent to so#-ins ire for rkeW compensation,as pmvidad for <br /> by Section 3700 of the Labor Cade,for the performance o the work for which this permit is issued. <br /> 1 have and will maintain workers'compensation insurance as requi by Secffon 3700 of the Labor Code, <br /> Nr the performance of the work for which this permit is iss od. My workers'cornponsat'ton insurance <br /> carrier and policy numbers are; <br /> Carrier I V-tA W e+ Policy Ulrrber: i <br /> 5 3 <br /> 1 certify that in the performance of the work for which this permit is hued, I shall not employ any person in <br /> any manner sq as to became subject to the workers'com ensetidn I!aws of Callfomfa,and agree that if I <br /> should become subject to the workers'compensation pro isians of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: l -0-7 Signature: <A <br /> Printed Name, -T-O "A t nz <br /> WARNING- FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN I:MPI.OYFPt TO CRIMINAL-PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN AnOITION TO THE COST OF COMPENSATION.IN TEREST,AMRNErS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN S1;CTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR 9THiER THAN 0.67 SIGNING PERMIT APPLICATION <br /> 1, (5i I1s4ura efCZ7 licensed authorized represantativg). <br /> hereby authorize(print name) ,�. <br /> to sign this San Joartuln County Well PermitApplieation on my behalf. I understand this authorlxatlon Is valid for <br /> one(1)year and is limited to the work plan dated on Lha front pegs of this application. <br /> a-Z9-02!Ml <br /> �Yp 7. 02-(301 <br /> ,GrY7 MA <br />