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EHD 29.01 07/20/10 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1010 Zephyr St., Stockton, CA PERMIT SR# <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#: 777007 Exp Date: 4/13/2014 <br /> Date: Vb, r J 1 Z Contractor: Enprobe <br /> Signature: Title: owner <br /> Print Name: Dennis Ott <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 /> "emit is issued. <br /> ►' I have and will maintain workers' Y <br /> compensation insurance, as required b Section 3700 of the <br /> p 9 <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: ��rr�� <br /> Carrier:�`��- -uNJ �,M jS Policy Number:c��W4f(,-� -111,20 <br /> 1 certify that in the performance of the work for which 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 provisio s of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those <br /> provisions <br /> /2- <br /> Exp. Date: 0 Signature: <br /> Print Name: / itii 5 L/ <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,Q�HER THAN C-57 SIGNING PERMIT APPLICATION <br /> y✓µl �- (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Doug Heard ,to <br /> sign this San Joaquin County Well & 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 the front page of this application. <br /> EHD 29.01 07/20/10 WELL PERMIT APP <br />