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RECEIVED <br /> JAN 2 7 2012 <br /> &-"v MUNMENTL HEALTH <br /> San Joaquin County Environmental Health Department PERMIT/SERVICES <br /> WELL& BORING PERMIT APPL'CATION SUPPLEMENTAL <br /> JOB ADDRESS: Ripon Farm Service 932 F'rcntageRDPERMIT 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 of the California Business and Professions Cod: and my license is in full force and effect. <br /> License#: 71 Exp Date: V�J� 12=0\1' <br /> Date: 2-0 VL Contractor: ca <br /> Signature: <br /> Print Name: <br /> WORKERS' COMPENSATIC IN DECLARATION <br /> I hereby affirm under penalty of perjury one of the followin j declarations: (check one) <br /> 1 have and will maintain a certificate of consert 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 and policy numbe-s are: <br /> Carrier:S a{ -e �- Vx-\,6 3olicy 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,rs' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with thosf provisions. <br /> L - -- 2.o = - <br /> Exp. Date:_ tZ <br /> _- _ Signature: <br /> Print Name: <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERA,;E IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IP 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 f9R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signah 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 authorizatior, is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> FHD 2"1 072&10 WELL PERNT APP <br />