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SR0071308
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2900 - Site Mitigation Program
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SR0071308
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Entry Properties
Last modified
9/19/2022 4:35:42 PM
Creation date
9/19/2022 4:29:38 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
BILLING/PERMITS
RECORD_ID
SR0071308
PE
2901
FACILITY_NAME
RALPH'S SQUARE
STREET_NUMBER
2122
Direction
S
STREET_NAME
AIRPORT
STREET_TYPE
WAY
City
STOCKTON
Zip
95206
APN
ROW
ENTERED_DATE
1/12/2015 12:00:00 AM
SITE_LOCATION
2122 S AIRPORT WAY
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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SJGOV\tsok
Tags
EHD - Public
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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /><..Z Lc..T h .._rp.-,rn :lay, <br />Lerit_�r.: :_. ^.Ck�,_n Z.: ch:. c. :-� ... Snc:::g i •�•.r <br />JOB ADDRESS: PERMIT SR # <br />LICENSED CONTRACTORS DECLARATION (LC) <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 #: Exp Date: '7/3 I 120 1C� <br />Date: Contractor: 0'2004�() fYQ/ / A)C7 <br />,- <br />Signature: <br />Print Name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />_f 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 />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:Cr►`IG1ICrQQ,f f )dUSl�i"C/ Policy Number: <br />I certify that in the performance of the work for which this permit is issued, l 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. <br />Exp. Date: /OII /2-01S Signature: <br />Print Name -AZ 80, , C, wnx 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 $1D0,000, 1N ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />rwALJTHORI ATLON,FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I°si nature of C- <br />( g 57 licensed authorized representative), <br />hereby authori (print name " " '' ='a`'"° <br />� , to sign this San Joaquin County Well &Boring Permit <br />Application on my behalf. I 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 />EH0 29.01 05.'09/12 <br />WELL PERMIT APP <br />
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