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EHD 29-01 07,'70!10 <br /> WELL I'MM,IT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Z%40?- R <br /> PERMIT SR # <br /> S46c1tL�,,� C. 015�.,0� <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#: �.� <br /> - , =xp Dale: <br /> Date: � '. Contractor. ,' <br /> Signature: Title: <br /> Print Name:_-_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under pedally 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 Cade, for the performance of the work for which this permit is issued. My workers' < <br /> compensation insurance carrier and policy number::: are: }} t <br /> Carrier: ( C 1 Policy Number: <br /> I certify that in the performance of the work for whit-i 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 pro�Jsions. <br /> Exp. Date: Signature: <br /> i <br /> Print Nam e: <br /> I <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 ADI:�ITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SEC-'ION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FQ_R THE THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature: 4of C-57 licensed authorized representative), <br /> f � 1CJl�,nV e.L� <br /> hereby authorize (print name) to <br /> sign this San Joaquin County Well 8. 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 tae front page of this application. <br /> 'cH029-0. 0726:16 V,ELL PGR},?!T AM, <br /> i <br /> i <br /> F " � <br />