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EHD 29-01 0720110 WELL PERMIT APP <br /> .a <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 15 Grant Line Road Tracy, California PERMIT SR# <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 Business and Professions Code and my license is in full force and effect. <br /> License#: 710Q79 Exp Date: 10/01/2013 <br /> Date: Contractor: WOODWARD DRILLING COMPANY INC <br /> Signature: _ GTitle: <br /> `' <br /> ' <br /> Print Name: �� C- V Y oo o+ <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 carriers and policy numbers are: <br /> Carrier:_ IYYY� KO-J&'1 �I�(V-(SiyQ policy Number: I�)rIL O. tJq (OC <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, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Cod , I s1hall forthwith comply with those provisions. <br /> Exp. Date: I 9,013 Si nature: n � <br /> Print Name: (+ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> %CRIMINAL PENALTIES AND'-6{VIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> -i"TQiRMELV'S FLE&.*#ftD DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l� (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> ,to <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> END 29.01 0720170 WELL PERMIT APP <br />