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SR0021673
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2900 - Site Mitigation Program
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SR0021673
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Entry Properties
Last modified
11/14/2022 10:50:01 AM
Creation date
11/14/2022 10:17:22 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
BILLING/PERMITS
RECORD_ID
SR0021673
PE
3501
FACILITY_NAME
CHEVRON
STREET_NUMBER
304
Direction
W
STREET_NAME
KETTLEMAN
STREET_TYPE
LN
City
LODI
Zip
95240
ENTERED_DATE
1/14/2000 12:00:00 AM
SITE_LOCATION
304 W KETTLEMAN LN
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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SJGOV\tsok
Tags
EHD - Public
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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS:,"- Loch 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 Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License* I A090 q� Expiration Date: LJ I I ho <br />Date: IVl: C tractor: V Z7 yJ I" I I I I a CN 14�c- <br />Signature: -a L Titltz <br />e: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrierandpolicy numbers are: <br />CarrierAdclen If -6 Policy Number: <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Sgction 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. n /l <br />Date: 1 1 \\\ GV Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />C-57 licensed authorized representative), hereby <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />
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