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San Joaquin County Environmental Health DDpartment <br /> j WELL He BORING PERMIT APPLICATION SI ;'•FPLEMENTAL <br /> JOB ADDRESS : 2154 S . EI Dorado St. , Stockton CA PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter g carnmencing with Section 7000) of <br /> Division 3 of thee California Business and Professions Code and my lil:-Irsl: is in full force and effect. <br /> License Exp Date: ! _1! 'fj)fy SDI <br /> Date: �� , c �th Contractor: �Xi { tfOY�t12fY Ei <br /> Signature: <br /> Print Nam <br /> aq --- <br /> WORKERS' COMPENSATION DECLARPwTION / <br /> I hereby affirm under penalty of perjury one of the following declaratir. ns : ('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 perfcrrlance of the work for which this <br /> permit is issued . <br /> x I have and will maintain workers' compensation insurance, as 'equired by Section 3700 of the <br /> Labor Code, for the performance of the work for which 111i3 aermit is issued . My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: JA-f 'tt Fu-SA Policy NaT(her: <br /> I certify that In the performance of the work for which this prrrmit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compeIisation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provision :; . <br /> Exp . Date, - y') P.l� 1 Signature : <br /> Print Name;, e/ A' . <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAVFFU=-, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100;0001 IN ADDITION `0 "HF: COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 i;4' "'H 1. LABOR CODE, <br /> AUTHORIZATION! OTR'fH , �.C -ST= SIGNINI ' PERMIT APPLICATION <br /> �-�--� <br /> Rob Slagle / r� (signature of C41 licensed authorized representative), <br /> rin , amei I tu ? 118r_, <br /> hereby authorye 6 to sign this San Joaquin County Well & Baring Permit <br /> Application on my ehalf. I understand this authorization is valid f; Ir ane year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHO'24-01 O�i2&HP WELLPERMIT APP <br /> F <br />