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f' <br /> San Joaquin County Environmental Health Department 41r'`"' <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> w ,� ch-� <br /> JOB ADDRESS: � b � PERMIT SR# <br /> LICENSED C CONTRACTORSADE LARATION (LCD) <br /> I hereby affirm that 1 wn 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 Jfull force and effect. <br /> License#: C.l 7Exp Date: <br /> Date: <br /> Contractor: I'!%ro" <br /> Signature: Title /G7l71�f'�Dh a�� <br /> Print Name: elwz - <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby a> ,aF somplay of perjury one of the following declarations: (check one) 1 <br /> IBpr airi t0 wWntain a certificate of consent to self-insure for workers' compensation, as <br /> vlded to *a Arcfion 3700 of the Labor Code, for the,performance of the work for which this <br /> palrW 0 a/aaia# <br /> I toe +w* 4m -sintain workers' compensation insurance, as required by Section 3700 of the <br /> La>ww 44ft vo she performance of the work for which this permit Is Issued. My workers' <br /> wow ance carrier and policy numbers are: <br /> Policy Number. �/ ' ��1`"��P✓ <br /> 1 amp"ow* eax Performance of the work for which this permit Is issued, I shall not employ any J <br /> pow, a am +arwner so as to became subject to the workers' compensation law of California, <br /> wd yN 9%w s should become subject to workers'compensation provisions of Section 3700 of <br /> the Labor Camw shall forthwith comply with those proMACZZ==- <br /> Exp,pats s/ /7" Signature: <br /> Print Name*. <br /> WARNING:FmsAM To WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHAD.SUBJECT AN EMPLOYER TO <br /> CCK PNkV*a!!1 AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,. :f. <br /> ATT0=Xr*p=L AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ZA <br /> OR OTHER THAN C-57 SiGNING PERMIT APPLICATION <br /> i� (signature of C-57 licensed authorized representative), <br /> hereby authorize(print mme) ., to sign this San Joaquin County Well & Boring Permit <br /> Application on n y balwtf. 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 /> r <br /> f WELL PERMIT APP <br />