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EHD22.0107/20A0 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL III <br /> nX03 <br /> JOB ADDRESS: 0X �O! �Or�� L gnP jkAul PERMITSR# v3�2 <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION (LCD) i <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#: Exp Date: <br /> �1 <br /> Date: O 3 e' Contractor: <br /> Signature: Title:Title: ZaEYG 00-0 zz&eaao <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: �Zk-er � Policy Number: lsg/% <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: C� //�z Signature: <br /> Print Namo�,,-C,- <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 3700 OF THE LABOR CODE. <br /> ZA OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C•57 licensed authorized representative), <br /> hereby au orize(print name) r X61�C- r7 Via (� 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 /> EHD2801 071 MIO WELLPERWTAPP <br />