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A <br />San Joaquin County Environmental Health Department <br />Unit IV Well Permit Application Supplement <br />Job Address: [ (1 "/ `� ��D�� G7 Permit SR #: d0� <br />A I p ... <br />' LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70(ItSIM <br />-316i <br />the Business and Professions Code and my license is in full force and effect. <br />License #: —�f C�y� <br />Contractor:�x�C'�� <br />Signature: <br />Print Name: <br />Expiration Date:. ©� <br />Date: S - ) 1 <br />Title:tL� <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 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, for <br />the performance of the work for which this permit is issued. My workers' compensation insurance carrier and <br />policy numbers are: <br />Carrier: li1fJ 1 y Q„),D Policy Number: O Lf q1L— b 2-6---3S <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 should <br />become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions. <br />Signature: .C6, Date: 15;- - I I —0-� <br />Print Name: L A.X�4\-D <br />Warning: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and <br />civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation, interest, attorney fees, <br />and damages as provided for in section 3706 of the Labor Code. <br />I, <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensed authorized representative), <br />hereby authorize (print name) -2,&-g }~fi54C , to sign this San Joaquin County <br />Well Permit Application on my behalf. I understand this authorization is valid for one (1) year and is limited to the <br />work plan dated on the front page of this application. <br />EHD 29-02-001 WELL PERMIT SITE <br />.1-1- <br />