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Apr 2511 03 :37p FISCH DRILLING !U / /68-y8U1 P . i <br /> d 1 <br /> San Joaquin County Environmental Health Department <br /> E WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 63Q GO i �trfn i a oj� � �7a'tPERMIT SR # _ <br /> Cr9- <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 CalfFomia Business and Professions Code and my license is in full force and effect. <br /> License #: 093 gb7 Exp Date: f nit` �- <br /> Date: Contractor: LLLU Jl)G- <br /> Signature: Title: d Cca <br /> Print Name: Davirl F25W <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (check one) <br /> 1 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 /> 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: 17 Policy Number: 0 E09as-s � l <br /> lb PEI <br /> 1 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: Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 590000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNErS FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> ALITHORIZATIO/�I FOR OTHER THAN C �57 SIGNING PERMIT APPLICATION <br /> I, �i� X (signature of Cm57 licensed authorized representative), <br /> hereby authorize (prink name) r_ 7BL L dad JC , to sign this San Joaquin County Well & Boring Penult <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 /> EHB 29-01 09111Y10 V.ELL PIMMITAPP <br />