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, <br /> i <br /> [ EHD 29-01 07120110 WELLPERMITAPP <br /> 6 San Joaquin County Environmental Health Department <br /> ZWELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> E.ADDRESS: �J 1 a • 6!04 yl f 001,1 PERMIT SR# <br /> La+tiro p,) CA- 0/6 33 b <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I <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#: C,S- 7 yleCA-r Exp Date: <br /> Date: ! Z / Contractor: G/ezr <br /> _ I <br /> Signature: ��__ Title: PlCi770�Zf ���i CY��T' <br /> Print Name: <br /> I <br /> WORKERS' COMPENSATION DECLARATION j <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 i <br /> provided for by Section 3700 of the Labor Cade,for the performance of the work for which this i <br /> permit is issued. <br /> l_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. Policy Number: <br /> f <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 /> i <br /> Exp. Date:_(3-L32 �/ Z Signature: <br /> Print Name: 4?,M °vo,� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO§10,0110,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 /> UT IZA N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby au orize(print name) 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 3091 OraM0 WELL PERMIT AR' <br />