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�.r Sao" <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 2-3x3 d 2-)Cs- ci. f3-n'- ,J 14o Dr;v< PERMIT SR# <br /> c");-1 P(.- J1) s <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 Code and my license is in full force and effect. <br /> License#: G-1-7 '` k�f ,I,,6-'� Exp Date: / As./ Z/ <br /> Date: Contractor: _ <br /> Signature: Title: <br /> Print Name: <br /> lt?b }tbW2 1�aad <br /> Batt{j,ne y dip, WORKERS' COMPENSATION DECLARATION <br /> tai) 31�i,ygpti ' <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 /> provided for by Section 3700 of the Labor Code, for the-performance of the work for which ails-'" <br /> permit is issued. f <br /> I have and will maintain workerscompensation insurance, as required by Section 3700 of the, I <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Ar.of, <br /> Policy Number: �/CwO-1 O10 <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 <br /> the Labor Cade, I shall forthwith comply with those provisio as <br /> Exp. Date: Signature: <br /> Print Name: L // /Ole <br /> aers' <br /> D SHALL SUBJECT <br /> WARNING:CRIMINAL PENALTIES AND CIVIL FIN ES UP TO$100,000,IIN ADDITION TOGE IS UTHE COST OF COMPENSATION,PINT REST,, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. -- <br /> U RI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION ^ry <br /> I (signature of C-57 licensed authorized representati ; <br /> hereby authorize(print name) Si�r ciE�,/Jk�l�c , to sign this San Joaquin County Well & Soring Per�rri <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the M?a <br /> plan dated on the front page of this application. ---- <br /> WFLL PI_r}fYnrwa <br /> EHD 28.01 OVW12 ; <br /> Ali'TO <br /> ".ST, <br />