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- r <br /> EHD 2801 07t20l10 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL_ <br /> JOB ADDRESS: 16500 Clifton court Road, Stockton 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 Business and Professions Code and my license is in full force and effect. <br /> License#: P, SID, Exp Date: b�► ' <br /> Date: Contractor. a ` a LQ nYl ' <br /> Signature: Title-.- fS\aenL <br /> Print Name: )rU, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing 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:i&tPolicy Number: ,91 <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'ccmpensation provisions of Section 9700 of the <br /> Labor Code, I shall forthwith comply with those provisions. rr <br /> Exp. Date:_ S 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$10D,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 /> AUTHORIZAT RX <br /> 4a&DTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hei;` Drl print name) Daniel Villanueva 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 plan dated on the front page of this application. <br /> ERD 28-01 071MID WELL PERWY APP <br />