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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 4-70-1 gACA�r_ 64' 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 California Business and Professions Code and my license is in full force and effect. <br /> License#: rA!-�(o q Exp,. (Date: t <br /> Date: t7,It5-Jugl Contractor: NGL✓t`Onct� 1� ,Signature: Title:� Title: ��� M O of aG 41 <br /> Print Name: CHQ—l5 ( ATU Y\ <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 /> Carrier. <br /> '-ZV JtG(I J nM-e AG c%n 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 provisions <br /> Exp. Date: <br /> 0 Signature: <br /> Print Name: <br /> WARNING D SHALL SUBJECT AN EMPLOYER TO <br /> CFAILURE TO SECURE RIMINAL PENALTIES AND NIL FINES TOO$100.000,,IINO ADDITIONE IS ,TO THE COST OF COMPENSATION,INTEREST. <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 0706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> /l f t h � (-� \ 1 l (signature of C•57 licensed authorized representative), <br /> hereby authorize(print name) . • to sign this San 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 PPP <br /> EDx lu. 12 <br />