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EHD 29-01 07/20/10 1�f WELL PER.MT APF <br /> 1 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 800 W.Church Street,Stockton,CA 95203 PERMIT SR# <br /> ,I <br /> I LICENSED CONTRACTORS DECLARATION (LCD) - ry <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> fff Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> € License#: C-57 485-165 Exp Date: l l/ / <br /> I _ <br /> Date: -7// Contractor: Gregg Drilling <br /> Signature: Title: <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I <br /> 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 l.-- - <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: � Policy Number: lC <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,:and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> Labor Code, I shall forthwith comply with those provisions. <br /> p. ha Signature: <br /> Ex Date: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYEWT.0-':''i- '• <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$700,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST;.::':' "` <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION j <br /> 1, (signature of C-57 licensed authorized representative)�:nu <br /> hereby authorize(print name) Tony Smith io <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this authorization,,,. <br /> is valid for one year and is limited to the work plan dated on the front page of this application. -. <br /> EHD 29-01 07/20/10 WELL Pt'f2WY APP <br />