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., ! <br /> ss > <br /> San Joaquin County Environmental Health Department <br /> APPLICATION SUPPLEMENTAL <br /> WELL&BORING PERMIT /oA <br /> 6A-, MIT SR# <br /> SOB ADDRESS: 31L, CD) <br /> CONTRACTORS DECLARATION (.L_ <br /> LICENSED with Section 7000) of <br /> rovisions of Chapter 9 (commencing <br /> license is in full force and effect. <br /> I hereby affirm that 1 am licensed under the e 3o I <br /> Division 3 of the California Bus and Professions CodeEandDate: <br /> 1�e�o <br /> License#: C� � <br /> ContractorlA✓fr <br /> a 1 3 p I S : C s <br /> Date: _ M Title: <br /> Signature: <br /> Print Name: ct�TlON DECIr^-DATION <br /> WORKERS' coMPENS. <br /> one of the following declarations: (check one) <br /> penalty of Perjury compensation, as <br /> ! hereby affirm under p Insure for workers' <br /> I have and will maintain a <br /> certificate of consent ftoo theperformance of the work for which this <br /> provided for by Section 3700 of the Labor Code. <br /> permit is issued' as required by Section 3700 of the <br /> I have and will maintain workers compensation insurance, perm !s issued. My workers' <br /> Labor Code, for the perfomTance of the work for which this p <br /> rrier and policy numbers are: I O <br /> compensation insurance ca Policy Number: <br /> 5 i <br /> Cartier: C� ermit is issued, I shall not employ any <br /> that !n the performance of the work for o ttthisworkerscompensation law of California, <br /> I certify compensation provisions Of Section 3700 of <br /> person in any manner so as to )ecome to workers' comp <br /> and agree that if 1 should become subject with those provision <br /> the Labor Code, I/shall forthwith comply l <br /> g. <br /> ,5 0 ZS D / — Signature: <br /> Exp. Dare: <br /> Print Name: <br /> TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP To 5100,000, IN ADD <br /> TO THE COST OF COMPENSATION. INTEREST, <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C�i7 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> I' to sign this San Joaquin County Well & Boring Permit <br /> hereby authorize(print name) <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMfT APP <br /> EHO 24D1 05!09112 <br />