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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: 53 Yr°01 N. tA.); Y 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 #: 55 6/ e <br />Date:- 3-"( ( <br />Signature: <br />Exp Date: (O (31 f'ici y <br />Contractor: Ac-CSO C • <br />Title: P("T u 12-0 rkA-A-)fmcf <br />Print Name: 1/---1- IN( G i.-6TH <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 />permit is issued. <br />k 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: CA4 kud-V-41-v-4,-4 N(S - Co, 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, and <br />agree that if I should become subject to workers' compensatiolirovisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provi 'o <br />Exp. Date: l ( ( / "Z-0 (H <br />, <br />Signature: <br /> -yr P <br />Print Name: ilLAA--0-77 t'-) <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 OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br />hereby authorize (print name) , 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 <br /> <br />WELL PERMIT APP