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`F <br /> E iD 24 31 07P2U1t41 WELL PERMIY APP <br /> San Joaquin County Environmental Health Department <br /> WELL $ BORING PERMIT AP'IpLICATION SUPPLEMENTAL 1 71 <br /> JOS ADDRESS." I16D Yj25EMIM A VEW&E PERMIT SR# <br /> /4 ASU re-eA . c A <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that l am licensed under the provisions-of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my iicenSe is in full force and effect. <br /> Luse#: C A 5 7#- g �'l 6 5 Exp Date:� l <br /> Date-, Cantractor: �' A?2 <br /> Signature. Title: r r <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I harsh affirm under penalty.of perjury one of the following,declarations (check one) <br /> I have and xvill maintain a certificate of consent to selMnsure for workers'compensation, as <br /> provided for by Section 3700 of the labor Cede,for the performance:.of the-work for which this <br /> permit.is�issued. - <br /> K11 have and will maintain workers'cwnpensation insurance, as required by Bection 37oci 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 numbers are: <br /> Carrier. Saedl � _Policy Number. <br /> I certify that in the performance of-the work for which-this permit-is issued, I shall trot employ arty <br /> perm in any manner to as to become subject to the workers'compensation lava of California,and � <br /> agree.that•if-I should became subject to workers <br /> compensation provisions of Section 3700 of the <br /> Labor Code,I shall forthwith comply with those provisia� <br /> Exp_ Date: 3-z b SIgtlare: <br /> Print Name: <br /> Vt1AI MING:FAILURE TO SECURE WORKERS'COMPENSATIOR COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CP41L FINES UP TO$1011,000,IN ADDmON•TOTHE COST OF COMPENSATION,INTEREST, <br /> - ATTORNEY'S FEES.-AND DAMAGES AS PROVIDED FOR IN SECTION.3709 OF THE LABOrt CODE. <br /> OATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t, .(signature a1 C-67 licensed authotized representative), <br /> ..hereby uthorite(print n_a It�e) L • ,tp <br /> sign this San Joaquin County Well&Boring Permit Application'on my-behalf. l-understlnd this authorization <br /> is valid for one year and is limited to the work pian.dated on the front page of this application. <br /> EH92M 07=0 WELL PERM APP <br />