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to rZ <br /> l <br /> San Jaequhr County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL. <br /> 1 <br /> JOB ADDRESS:a_iF'-D'j_T7 � (,ICG PERMIT SR if <br /> t"Jf —ISD�o Se�uo-�-� Ole 3 Lto 3 <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I hereby affirm thou I am licensed under the provisions of Chapter 9 (commencing with Section 700D)of <br /> Division 3 of the Caltfornia Business and Professions Code and my license Is in full force and effect. <br /> License#- 4©�y 684 Exp Date: � 1r�Cr11 <br /> Date: 8/5/11 Contractor. _ PeneCore Drilling <br /> Signature: TIIle: CEO <br /> Print Name: Iu a u en <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following d'edaratbns:(check one) <br /> I have and will maintain a certiflcale of consent to self-Insure foe workers' compensation, as <br /> Provided for by Section 3700 of the Labor Cade, for the performance of the work for which this <br /> permit is issued. <br /> have and will maintain workers' compensation Insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the wank for which this permll Is Issued, My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: State Fund Policy Number: 000'0594392010 <br /> 1 certify that in the pertonnance of the work for which this permit is issued, I shall nal employ any <br /> person in any manner so as to become subject to the workers'compensation law of Galifomis, <br /> and agree that if I shou9d become subject to workers'compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with[haze pmyislo-ns, <br /> Exp.Date: 81111'2 Signature: ,"LA/` <br /> Prinf Name: [T 'gan Nguyen <br /> WARNING:FAILURE TO SECURE WORIa:RV COUPE SATION COVERAGE 13 UNLAyIFUL,A.NO zhA L Su63EOT AN UPLOTER To <br /> "PAIRIAL PENALTIES AND GWIL FINIS UP TO IM,ee0.IN ADOMON TO TNO COST OF COMPEN9ATION,WYEREST, <br /> ATTORNEY'S FM,AND OAIAAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR COOS, <br /> AL THO TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 Ilcensed authorized representative), <br /> hereby authorname)SrpI(i. to sign this San Joaquln County Wen & Boring Permit <br /> Appllcation 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 /> cn x.a� o�re�o Neu n:xu,u... <br />