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� row Flo - �r36-S . -.y <br /> A� > Ilz���lti RECEIVED <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTA <br /> IVIRONMENTAI,HEALrH <br /> PERMIT/SERVICES <br /> JOB ADDRESS: �2� �A.s r ) 7 ' �� " <br /> �F�`-'fPERMIT 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#; 9 3q q I Exp Date: f)(013011-5— <br /> Date: <br /> )(o .3U SDate: 57/20 Contractor: JUM <br /> Signature: Title: P P—C S z T7y T <br /> Print Name: BOA CLAP--C- R.ZbD6 -L- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (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 perfcrmance 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 /> Carrier:,�iA�E?. NO jnS' FL n j Policy Number: <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 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 provisions. f<v�y <br /> Exp, Date: :7 - � gvory Signature: e �G=� <br /> Print Name; (jleno Ia )e e i S <br /> WARNING.FAILURE To SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> C,RININAL 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 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 /> CHO 29-01 DSR9112 WELL PEkm(APP <br /> t <br /> TO/TO 3SVd AN0700 I31VNVH E6869Z8808 Lb:ET b103/Z0/90 <br />