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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT 'APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: S A/ p;5/lrl . / ?<- liGl PERMIT SR# <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 #: <br /> Ex Date: �3y /f <br /> ��7- `73�//U P <br /> Date' 6� /S 7e,111 Contractor: <br /> Signature. Title: ��/ ��✓ <br /> Print Name: 2 A <br /> WORKERS' COMPENSATION 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 /> 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 /> compensation insurance carrier and policy numbers are: <br /> carrier:��`Ln \ y�\��XZCJ 1 Policy Number. �(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' compen ion provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with tho�7' <br /> ons.�Exp. Date: )U2- � Signature \�\ <br /> Print Name <br /> LOYER <br /> WARNING' FAILURE TO SECURE WORKERS'COMPENSATION <br /> PENALTIES AND CIVIL FINES UP TO $100,00, IAN ADDITION GE IS VTOUN <br /> THE COST <br /> OF COMPENSATION,D SHALL SUBJECT AN T, <br /> INTEREST, <br /> CR , <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> p UT ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> tr Il -, �� (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name)VOW--\ t�LJJ,� 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 /> WELL PERMIT APP <br /> EHD 29-01 OV29I10 <br />