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WELL PERMIT APP <br /> EMD 2941 07M10 <br /> ! San Joaquin County Environmental Hsaith Department <br /> e <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 1 <br /> 833 East 8th Street, Stockton,CA PERMIT SR# <br /> JOB ADDRESS: —__., _ <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 /> jDivision 3 of the Business and Professions Code and my license is In full force and effect. <br /> License#: _906899 — Exp Date: 11I3QI11 -- <br /> ? Date: 10/28/11 <br /> Contractor. Penecore Dulling <br /> Title: CEO <br /> Signature: —— `- <br /> Print Name: <br /> -. Tuan Ncil VenI <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following 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: State Fund Policy Number:ri4�-tltltl(1731-11 <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 Calffomia,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Gate: <br /> 8/1/12 _ Signature: <br /> Tu Nguyen <br /> Print <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT AN EMPLOYER TO <br /> CRMAWAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO TME COST OF COMPENSATION.INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IH SECTION 37"OF THE LABOR CODE. <br /> E TH RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-5711csnssd authodzsd represenbdlve), <br /> sirsthis SanrJoa uln County Well&BorinnPermit AppNCadon On my behalf. I understand� <br /> y (P <br /> � q this authorization <br /> Is valid for one year and Is limited to the work plan dated on the front page of this application. <br /> WELL PERM11 APP <br /> Eroaoi o�,70+0 <br />