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San Joaquin County Environmental Health Department <br /> WELL Hr BORING PERMIT APPLICATION 1SUPPLEMENTAL <br /> JOB ADDRESS: (oyLi CAPi�nL ►�}�� Gou; (t7PERMITSR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 Cocle and my license is in full force and effect. <br /> License#: $�` =xp Date: l ol, �^�Il <br /> Date: � '2�1"Z� 1 Z Contractor: - IA k\ w,C,'F \ (1 V (1Qrl� I lP l <br /> Signature: �� Title: .. <br /> Print Name: h/6 f VA <br /> WORKERS' COMPENSATICIN DECLARATION <br /> I hereby affirm under penalty of perjury one of the follown I declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 1 have and will maintain workers' compensation nsurance, 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 /> compensation insurance carrier and policy numbe s are: <br /> Carrier:�A t �1� 'olicy Number: 101-1 � D <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with thOSE� provisions. <br /> Exp. Date:JSignature: ._ <br /> Print Name:_. w C ICS a L� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERA( E IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SEI;TION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57' SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Tim Cuellar to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 28-01 07126'10 WELL PERMIT APP <br />