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San Joaquin County Environmental Health Department <br /> WELL Hr BORING PERMIT APPLICATION SUPPLEMENTAL <br /> FJOEBADDRESS: 9()d T-r0U5t-n al l "Y 1 I C+ C7 Sd 9c 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#: L� 7 0,1 Exp Date: D H r 30/� ,I 5- <br /> Date 03 '15 <br /> Contractor: <br /> dt? i1 0. 417J('Qrscl-� L ASSOCi 4i .1,17t <br /> Signature: d Title: 1461 . <br /> Print Name: E'vc O. �N062to 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 /> V 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: > v ♦FYI Policy Number: '��Trr( 4'3ib13) <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 provis,OR� <br /> Exp. Date:__Q Sl a)/ 70 i Signature: <br /> Print Name:_ <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> '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' (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 /> EHD29-01 0e 9/12 <br /> WELL PERMIT APP <br />