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01/10/2014 15:42 FAX 9163722585 WALLACE-HUHL AND ASSOC. 0003 RECEIVED EHD A01 0720110 jarj 1 rIWEI.,PERMITAPP San Joaquin County Environmental Health Department ENVIRONMEN L WELL &MBiORING PERMIT APPLICATION SUPPLEMENTALHEALTHDEPA.RTMEN JOB ADDRESS: So , 1 y I`t 6J0 960,,Q 1V) PERMIT SR# LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in fu11[I fo ce an effect. License#: l Exp Date: LA 4 Date. Contractor: n ku Signature: ` Title: Print Name: WORKERS' COMPENSATION DE ARATION I hereby affirm under penalty of perjury one of the following 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. �j I have and will maintain workers'Compensation insurance, as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: �tZ( �1 I Policy Number: I certify that in the performance of the work for which this permit is issued, I shall np4mploy any person in any manner so as to become subject to the workers' ensation la of C lifomia, and agree that if I should become subject to workers' Gompensatio \ro sions of S4*tion 700 of the Labor Code, I s II to hwith comply with those provisio ' . r Exp. Date: Signature: Print Name: r 1 r I I/` WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJES�.�1 EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITIDN TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. AIJTHORI TION 1FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION Y `L (signature of C-67 licensed authorized representative), hereby authorize(print name) MQ M ,to sign this San Joaquin County Well & Boring Permit 4plication 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. FyD zcm onays ,.F. �.....�..