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San Joaquin County Environmental Health Department <br />Unit IV Well Permit Application Supplement <br />Job Address: 42/7 f 74 (.-1 /3;74 .acie6,,,, a 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 3 of <br />the Business and Professions Code and my license is in full force and effect. <br />License #: <br /> <br />Expiration Date: ?A <br /> <br />Contractor: GriOolez-- ,71'a7 (n <br /> <br />Date: <br /> <br />Signature: Title: <br /> <br />Print Name: L-40 #77 . 6(./.0eva(c.i_ <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 />IIII'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: ,_57 74- /2-7=LAI C77 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 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: <br />Print Name: Co C11 7 Gtoc)474,c >—e-i <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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, >o-77....c.4,7-7, 600 -cr-Z--c-trz4-etiO (signature of C-57 licensed authorized representative), <br />hereby authorize (print name) Da c, ( ,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 />Date: 3// 7/0 4 <br />0 hl