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15, `, = 2-9.6 t <br /> • �-� 20 I r 6r�1�"X� �K�.t x 30 = (o0 6��� = 2-16s <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> Zoon 5hM56n1 sdK --) /o(0J s6g- �iw- vfoc <br /> JOB ADDRESS: WrA(1 rL Ste( !)ufL-r (, (j i PERMIT SR#<' <br /> / cipr <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 California Business and Professions Code and my license is to full force and effect. <br /> License ax. J03(0 3 1?-1 1 f 2,11 2-01 3— <br /> Exp Date: <br /> Date: Contractor: PIREC4S l0xJ SA4-i0L-4 N6, i�lG <br /> Signature: Title: OPFR-A�-T1oNS <br /> Print Name: BQF/J�iF C4WF0f-'b <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 /> X 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 /> Cart AW I oAJ Pica P LT-4 <br /> Carrier: A+Jb u►5yA4--r1,1 Policy Number: LPCA- 10cI(o(p <br /> I certify that in the performance of the work for which this permits issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California. <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pr visions <br /> Exp. Date: I30I 1-0 11 Signature: <br /> Print Name: A"-k)D A CJA f FD� <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 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> bRFN-DA G4t4NWF0" (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name A S+e,2 n sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this auth ization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> WE Ll PERM(?AFP <br /> I M OTz�I <br />