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WELL PERMIT APP <br /> EHD 29-01 07/20/10 • • <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> FJOBAIDDRESS: 8530 In/• L1nn ¢ 12,4 , <br /> --7/a Gy PERMIT SR # <br /> � <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 q Exp Date: �WX-4 Q, 21 <br /> Date: <br /> Contractor: Oer%o f vP 94\s n(a <br /> Signature: v j� -/,'� / Title: r� - <br /> Print Name/IUtin <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: S;+Ck+e k)n A Policy Number: ` LH 1-7 3 j 1 1 <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 provisions. <br /> Exp. Dater Iy xI SI1 I )�Z Signature: <br /> Print Name: C L" <br /> LL SUBJECT AN <br /> WARNING: FAILURE TO SECURE <br /> PENALTIES AND CIVIL FINES UP TOn$100,00,INAADDITION TO THE COGE IS UNLAWFUL, ST OFACOMPENSATION, TO <br /> INTEREST, <br /> EMPLOYER <br /> CR <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 /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) j6W%0(Latif 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 /> WELL PERMIT APP <br /> EHD 29-01 0720!10 <br />