My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
FIELD DOCUMENTS
Environmental Health - Public
>
EHD Program Facility Records by Street Name
>
Y
>
YOSEMITE
>
2600
>
2900 - Site Mitigation Program
>
PR0543549
>
FIELD DOCUMENTS
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
9/18/2018 11:57:49 AM
Creation date
9/18/2018 11:56:46 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0543549
PE
2950
FACILITY_ID
FA0024729
FACILITY_NAME
GREAT WOLF LODGE
STREET_NUMBER
2600
Direction
W
STREET_NAME
YOSEMITE
STREET_TYPE
AVE
City
MANTECA
Zip
95337
CURRENT_STATUS
01
SITE_LOCATION
2600 W YOSEMITE AVE
P_LOCATION
04
QC Status
Approved
Scanner
TMorelli
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
2
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
Signature of C5U <br />San Jo _Ain County Environmental Health Dep, .ient <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 2600 W. Yosemite Ave. PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <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 />Contractor Name: 4u0fl 1\ <br />Expirati n Dat c)/C' <br />Title: <br /> Date: <br />License #: <br />Signature: <br />Print Name: <br />WORKERS' COMP SATION 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 <br />1:1 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 />com-piensat on i urance c rrier and policy numbers are: — <br />Carrier: )L t n() Policy #: -)(..)(:).74--,/ Exp. Date: it) ' <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 law of California, and agree that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />T. hwith comply with t ose provisions. <br />Signature: LI) <br />- <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> <br />44UTHORI TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />:‘1 .,(11 1 17 II , hereby authorize <br />tt. Till/ itiq N o of C-57 Licensed therao opresontativo Pri Name o o <br />ne:wizeaei <br /> <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand fis <br />authorization is valid for one year nd is limite to the wo k plan datT:1 on the front page of this application. <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application
The URL can be used to link to this page
Your browser does not support the video tag.