Laserfiche WebLink
G< zn znnr 13 39 9166385611 en• [u, [Vu/ CASCADEDRILLINGll: ISAni PAGE 02/0rg' eonvlronmental <br /> No, /689 t <br /> 6AI ° F`cos <br /> II&P/2 <br /> San Joaquin County Environmental Health Department Unit IV Weii Permit Applicatio supplement <br /> JOB ADDRESS��/03 CEus PERMIT SR#�O�C? $ob 59 <br /> 2 /SO t� 5obf¢0 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and J Professions Code and my license Is In full force and effect. p <br /> License* —=� 1 0 //�-Expiration Date: <br /> f —� I ` C� <br /> Date: - i - Q Gontractnr /�rl " I ( I nc, <br /> Signature: Title: IJD �� ( d rl,�_ <br /> Printed name; <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under pennity of perjury one of the following declarations! (CHECK ONE) <br /> _( have and will maintain a certificate of consent to self-insure for workam'compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work fnrwhioh this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is Issued. My workers' compensaVon insurance <br /> carrierandpolicy numbers are; c��7 <br /> Carrier:f"t r:-,V '� lV C(-( <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workars'oornpensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with ihoaeprovisions. <br /> Expiration Date; 0-7 signature; <br /> Printed Name; I v A Ae� <br /> WARNING; FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SU9JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION $706 OF THE LABOR CODE, <br /> A�RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature ofC-57 licensed authorized representative), <br /> haraby authorize(print name) <br /> to sign this San Joaquin County Well Permit Appncktlon on my behalf, I understand thin authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 8-29-021 Ml <br /> &HD 29,02-001 <br /> aMrru <br />