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EHo 29.01 07/20/10 <br /> WELL PERMIT APP_ <br /> I San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 800 W.Church Street,Stockton.CA 95203 PERMIT SR# i <br /> i <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 Business and Professions Code and my license is in full force and effect. <br /> License#: c-57 485-1{i5 Exp Date: 31 January 2013 <br /> nate 17 July 2012 Contra tor• Gre-!?g,Drilling <br /> Signature: _ Title:A71 <br /> e <br /> Print Name: Cr <br /> h <br /> WORKERS'COMPENSATION DECLARATION <br /> E <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) s <br /> 1 <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 i <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: Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> j 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 the <br /> Labor Code, I sh 11 forthwith comply with those provision <br /> Exp. Date: l 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$700,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 8700 OF THE LABOR CODE. <br /> ORI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. .. (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Tony Smith to <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 pian dated on the front page of this application. <br /> EHD 29-01 07=110 <br /> WELL PERMIT APP <br />