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'- 4..X`....�_>._i.:.,...:_�.....:_�.........,..x.G::.s...Y::i:$a>_....S:L..=.._u.w...�t.;::...:........_r._5iEi5)3'iSr::.:eh�_'s'i.»..t.,;.,-.,........v.:•i�`t3i4ii.Y"•a <br /> s , <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS; ` 1 E,, /A(n 1 vL e 1AVe S�oc K��� (kPERM rr SR# <br /> y S"au1" <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 /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License#: Exp Date: <br /> i <br /> Date: Contractor: G451-mlf 09e,0`lip <br /> Signature / Title:Print Name: <br /> Blame: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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: �(}}�'� Policy Number: <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 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 those provislo s. <br /> Exp. Date: � ( f Signature: <br /> Print Name" 6cam <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRiMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUT t N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to sign this San Joaquin County Well & Boring PerAt <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the wort. <br /> plan dated on the front page of this application. <br /> i <br /> EH D 29-01 05/09112 <br /> WELL PERMIT App <br /> I: <br /> S <br /> t'p <br /> 4 <br /> fi <br /> f <br />