Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1 ki(6C �Y"�-1 PERMIT SR #: <br /> ovLw1ru�1 U; , C*' <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: <br /> r� t ) <br /> License #: ( 1 Expiration Date: t4 - i <br /> Signature: 1(,(,Q -Title: <br /> Print Name: Sf rV i 1 Date: 3 I <br /> WORKERS' MPENSATION 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 /> coom ensa ion in nce carr er and policy numbers are: <br /> s1 1Carrier: svof k j Policy#: T— Exp. Date: (/ I r� <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 ta�h orkers' compensation law of California, and agree that if I <br /> should become subject to workers' compensation provisiorLkof Section 3700 of the Labor Code, I shall <br /> forthwit comply with those p ovisions. <br /> ` h <br /> Signature: kla <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' MPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AU HO ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize <br /> Noma d G Ltcenaatl AuttansaA RaProaamNrva r""� mt Nama of AutAorizad Aganf <br /> to sign this San Joaquin Coun Well &t Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one y ar and is invited to'the work plan dated on the front page of this application. <br /> ipnatun of C47, cans uta Rapm"n <br /> S <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />