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Nee <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Ripon Farm Service 932 FrcntageRDPERMIT SR# <br /> Ripon Ca <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions o Chapter 9 (commencing with Section 7000) of <br /> Division 3 offtthtelCalifornia Business and Professions Cod s and my license is in full force and effect. <br /> License* C� 1 6yi, Exp Date: 1015� 12-0\1- <br /> Date: ` 1 1 �Z Contractor: CA�k UJC LkA- <br /> Signature: -�'�Title: ' <br /> Print Name: c S� C <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followin t 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 'or which this permit is issued. My workers' <br /> compensation insurance carrier land policy numbe's are: <br /> Carrier:Sk a{ -e 1 uriw' policy 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 :o the workers' compensation law of California, <br /> and agree that if I should become subject to work ars' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with thosE provisions. <br /> Exp. Date: ��- Signature: <br /> � ` � �-'4................._....._._ <br /> Print Name: 3 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAI.E IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, D 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_EQR OTHER THAN C-51 SIGNING PERMIT APPLICATION <br /> (signatt re of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to sigr 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 /> EHE 2"1 0712&10 VVEU PERMIT APP <br />