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EHD 24-01 07/20/10 WELL PERMrr APP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> i <br /> JOBADDRESS: SfdZ'1CTQri�,lF} 95�aDTo 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#: �� # 73 O Exp Date: <br /> Date: /WHRC4 /S, -4 O/,2 Contractor:_1�0�9"AsC LA/V-, %n L" G+1 HETi(',C)l <br /> Signature: �r` Title: PK6JEZT M&F�PGt`72. <br /> Print Name: OHTI �1><_T1Ct 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: PROD ti4ftO'IM pNSUPA\x.CPoIIcy 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,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 provisiogs. <br /> Exp. Date: J F 30 a0 0 Signature: <br /> Print Name: D�1 N�yC�y <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 r (signature of C-57 licensed authorized representative), <br /> hereby uthorize(print name) PE - e '--6Vz&) ,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 /> EHD 29101 07/20110 WELL PERPAT APP <br />