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.............. - <br />San Joaquin County Environmental Health Department <br />WELL & B09INO PERw APPLICATION SUPPLEMENTAL <br />1p. <br />I hereby affirm that I ani 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 In full force and effect: <br />License #: Exp Date: 01 AI LA00- <br />Date: =tom contra.ctor:. 1121r.SG <br />Signature: . e Title: <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 />V 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: 1&)Sgftg6 C•'olidy Number: W 14 f 10�b � <br />I certify that in the performance of the work for which this .permit is issued,, I shalt not employ any <br />person in any manner so as to become subject10 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 provision <br />Exp. Date- LU/1 Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $1001000, 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 />I, (signature of C-57 licensed authorized representative), <br />hereby authorize (print Homey ; to sign this San Joaquin County Well & Boring Permit <br />Application on my behalf. I understand this authorization Is valid for one year and Islimited to the work <br />plan dated on the front page of this application. <br />EF ID 2 107raH0 WELL PERMIT APP <br />