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EHD 29-010720H0 <br /> WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 14749 N. Thornton Road, Lodi C 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#: 11 t (, Sc� �w 4 ` <br /> E:xp Date: KVNA ' �L` 1 '�L( Lt <br /> Date: Contractor: <br /> Signature: Title:_ '� \dwy o- <br /> Print Name: V V -� G <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 sslf-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: E \t Policy Number. <br /> 1 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' ccmpensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provision <br /> Sj <br /> Exp. Date: Signature: <br /> Print Name:_ innlay} 0 <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 /> AUTHORIZATI %9.--Q-P,-DTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. (signature of C-57 licensed authorized representative), <br /> hereby at„orie(print name) TIMOTHY Coes.n., f <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorizaf <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD i9 21 172C/10 <br /> AEL'. <br />