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E N E D <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTA II <br /> IRE3NMEfu 'RE.HEAL rH <br /> PERMIT/SERVICES <br /> JOB ADDRESS: tc/qS r TP <br /> MIT 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 California Business and Professions Code and my license is in full force and effect. <br /> License#: 93L/ Exp Date: O/DI301 f s <br /> Date: 512 Contractor: _aJUGrA S <br /> S <br /> Signature: %�7 LL�/�<i� t Title: _P WLS z T7F Aj r <br /> Print Name: BOB C&ipk- 9-r DD L.1-- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrior: r10, ' FLnjPoliy <br /> I 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 Califomia, <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 provisions. <br /> Exp. Date: - i -7- gory Signature:.,� <br /> Print Name: Gknr7 >Q ��f <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIRUNAL PENALTIES AND CIVIL FINES UP TO 5100,000, IN ADDITION TO THE COST OF COMPENSATION. INTEREST. <br /> ATTORNErs 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 name) to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> Diff 2641 05106111 WELL PGkm f APP <br /> 1 <br /> TO/10 39dd ANO-100 I3-lVNCH E6869Z8808 Lb:Ei bI0Z/Z0/90 <br />