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02-27-12;02: 12PM; ;916 679 2422 # 2/ 2 <br /> EHD 2909 07/20/10 <br /> WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Z�C1C2 t���aGLG Cc.�f/J�s L f'AWPERMIT 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#: Exp Date: x/7///4 I <br /> Date: 2 E) 2 Contractor: <br /> Signature: // Title: <br /> Print Name: A'/ <br /> WORKERS'.COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> XI 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: /2f�y� £ PoLIcy.Nulnber:��C(il.�O/O y�rO� <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 Code, I shall forthwith comply with those provision <br /> Exp. Date: (5- Signature: <br /> Print Name:_��//rrL/11�7'/' <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 3706 OF THE LABOR CODE. <br /> IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> �T�H <br /> ry'� )�" <br /> (Signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) �/UI(fi/ij[. �� /{yy(/G(� G�f (�iyrS <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 /> 6110 29-01 07/20110 VVEn.PERMITAPP <br />