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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL .JOB ADDRESS: 601 N Hunter Street, Stockton, CA PERMIT SR # . LICENSED CONTRACTORS DECLARATION (LCD) I hereby affinn that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Californiaf�Business and Professions Code and my licensissin II force and effect, License #: �� Ex Date: Date: '-A Contractor; Signature: t-� - , 1 Title: �C 1dC__. �. I Print Name: 4 !� WORKS ' COMPENS TION DECLARATION I hereby affirm under penalty of perjury one of the fallowing declarations. (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the perfonrance of the work for which this permit is issued, My workers' compensat' n ins ranc carrier and policy numbers are: Carrier: �.. Policy Number, 5t��-'} " / / ` �,(� f I certify that in the performance of the work for which this permit is issued, I shall not emplo any person in any manner so as to become subject to the workers' co , pen�Ttion law of Galif rnia, and agree tha if I should become subject to workers' compensatlo rovisions of Section 3 00 of the F-abo' C((q e i shall forthwith comply with those prov' IIon�f Exp. Date: {� Or • --- Signature: Print Name: /? �' '7 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT AN PLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST of COMPENSATION, INTEREST, ATTORNEY' TEST AND DAMAGES As PRO IDED FOR IN SECTION 3706 OF THE LABOR CODE. 2AUn I TION FOR OTH THAN C-57 SIGNING PERMIT APPLICATION signature of C-67 licensed authorized representative), hereby authoriz tname)�lf)��"'r` ('G-6" _- to sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. EHD 29-01 0510.9112 WELL PERMIT APP rl San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL .JOB ADDRESS: 601 N Hunter Street, Stockton, CA PERMIT SR # . LICENSED CONTRACTORS DECLARATION (LCD) I hereby affinn that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Californiaf�Business and Professions Code and my licensissin II force and effect, License #: �� Ex Date: Date: '-A Contractor; Signature: t-� - , 1 Title: �C 1dC__. �. I Print Name: 4 !� WORKS ' COMPENS TION DECLARATION I hereby affirm under penalty of perjury one of the fallowing declarations. (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the perfonrance of the work for which this permit is issued, My workers' compensat' n ins ranc carrier and policy numbers are: Carrier: �.. Policy Number, 5t��-'} " / / ` �,(� f I certify that in the performance of the work for which this permit is issued, I shall not emplo any person in any manner so as to become subject to the workers' co , pen�Ttion law of Galif rnia, and agree tha if I should become subject to workers' compensatlo rovisions of Section 3 00 of the F-abo' C((q e i shall forthwith comply with those prov' IIon�f Exp. Date: {� Or • --- Signature: Print Name: /? �' '7 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT AN PLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST of COMPENSATION, INTEREST, ATTORNEY' TEST AND DAMAGES As PRO IDED FOR IN SECTION 3706 OF THE LABOR CODE. 2AUn I TION FOR OTH THAN C-57 SIGNING PERMIT APPLICATION signature of C-67 licensed authorized representative), hereby authoriz tname)�lf)��"'r` ('G-6" _- to sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. EHD 29-01 0510.9112 WELL PERMIT APP