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Ban Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> [hereby <br /> RESS: 4-70'/ pPCAV711 Age. LT (yam I fiA_PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 3ec <br /> ion <br /> th <br /> ion <br /> of the Califomia Businessnder the provisions of and Profe sions Code andpter 9 my I cense sen full forncing ice andtefect.DO) ofEcp Date:: y-- <br /> lz t - I Contractor. �� aEWO I G <br /> Date: t <br /> ��— Title: � Ata a Q -tl <br /> Signature: <br /> Print Name: <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 carrier and policy numbers are: <br /> Cattier: �'ZVit( A AIM- <br /> v'\CAv-) 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 o rs'compensation provisions of Section 3700 of <br /> With the Labor Code, I shall forthwith comply those P 1j <br /> Exp. Date: 0 17 Signature: <br /> r? <br /> Print Name: <br /> SUBJECT <br /> LOYER TO <br /> WARNING FAILURE TO SECURE CRIMINAL PENALTIES AND CIVIL FINES UP TOO$100.OO�IN ADDITION To THGE IS UNLAWFUL,E COST OF COMPENSATION.INTEREST, <br /> ATTORNEY'S FEES.AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (,;�k �Lh `(,�,}1� t��� (signature of C-57 licensed authorked representative), <br /> hereby authorize(print name) .1.L— � • to sign this Ban Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization Is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMIT APP <br />