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n <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SI,1PPLEMENTAL <br /> JOB ADDRESS : 2154 S • EI Dorado St ., Stockton CA FlUtfiIIIT SR # <br /> LICENSED CONTRACTORS DECL/ i, : 1PITIQN ( LCD ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 5 ;commencing with Section 7000) of <br /> Division 3 of the <br /> �California Business and Professions Code and my iii : ;r seq is in full force and effect. <br /> License #: c� Exp Date : , 1 �1 0-ar1b_ <br /> Date: rv ,1 1 th ! Contractor: � . <br /> r,. <br /> Signature : Title: <br /> Print Name: :r �1 <br /> WORKERS' COMPENSATION DECLAIZIP TION <br /> 1 hereby affirm under penalty of perjury one of the following declaratic n, : r' 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 gequired by Section 3700 of the <br /> Labor Code , for the performance of the work for which 1113 oermit is issued, My workers' <br /> compensation insurance carrier and policy numbers are : <br /> Carrier: s"� ft � 1, AA Policy NU nber: C11E] I " <br /> I certify that in the performance of the work for which this pI: rmit is issued , I shall not employ any <br /> person in any manner so as to become subject to the wort, els' compensation law of California , <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with thosr= provision/ — " <br /> Exp. Date:%(' fY-�`7 P ii� 1 .',-7) Signature : <br /> Print Name <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAAIrU._, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $10(l 114 ADDITION `0 "HF COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 04H4: LABOR CODE, <br /> AUTHORIZATIONOT, H , 1 -5X-SIGNING'. PERMIT APPLICATION <br /> 10 Rob Slagle '^r ` (signature of C-51 licensed authorized representative), <br /> hereby authorive (pr�i tfatne) T Uellar to sign this San .IoaquIn County Well & Boring Permit <br /> Application on my Behalf. I understand this authorization is valid f :Ir me year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29.01 0712NIO WELL PERMIT APP <br />