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R. ,< E <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTA <br /> rIRDNr�Ef� AI.i-ILA H <br /> If PERMIT/SERVICES <br /> ADDRESS: �2 I 1 S �.T_ 2MIT 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#; 3�41 Exp Date: <br /> Date: Contractor: <br /> 2 �� `� Contractor: <br /> Signature, ► f T—�7' %L G Title: 'P L <br /> 2=F S z T7 ,y T <br /> Print Name: BOB CL4pk- 9_Sb,D6L,1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following deciarations: (check one) <br /> 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 /> 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 parmit is issued. my workers' <br /> compensation insurance Carrier and policy numbers are: <br /> Carrier:,ell�o�e Ce Aje &S' )CL,ne Policy <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 4t14 <br /> Exp. Date: -7 - i Ory Signature: � ry 2 ,� <br /> Print Name; Genn ,o lee i <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPL-OYER To <br /> CRINUNAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADOITION 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 /> 1 p <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 worts <br /> plan dated on the front page of this application. <br /> DID 20-01 0i100,t1 WELL KkMYr APP <br /> I <br /> l0/T0 39t1d AN0700 I31VNVH E6869Z8808 Zb:CT 010Z/Z0/90 <br />