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EH02"I 07/20/10 <br /> WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL S BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I IHwalu I•T01br. pdc f'P A,d 62 W &-i1 a N wtt n.-PERMIT SR i <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#: 706 S6<?� Exp Date: 5 31 1 1.013 y <br /> Date: J ^ <br /> �. Contractor: EGG 0p, 1CY\V% CO�J XOTIA, <br /> Signature: 11 Title: S al ,nil <br /> Print Name: E��. <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 /> a^ <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 /> Carrler: 4 Q Ca I Tive � cwuc Policy Number: :LZ W EG1,Y 99-43 <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 /> Print Name: _ lk , , (A)ALL',a— <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO 600,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, -IV l-- l (signature of C-57 licensed authorized representative), <br /> hereby alithortze(print name) It 10e/d<tv wP �Vp4h c U< to <br /> sign this San Joaquin County Well R Boring Permit Application on my behalf. 1 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 /> EH 2] W W10 <br /> WELL PERW APP <br />