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PT, 4fIzrA�y 6�4' <br /> -� t9 <br /> San Joaquin Coun Environ nt Health Department Unit Well Permit Application 5p lom nt <br /> � <br /> 1/ W !v <br /> JOB ADDRESS: !;0 w• ro '1 PERMIT SR#� <br /> —wo Lw-. 6*'` d 51 S T 6 <br /> sl?4 <br /> LICENSED CONTRACTORS DECLARATIONL(Ca) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: � 5Firation Date: '`C��� <br /> Date: C j/ Ci 7 Contractor. <br /> Signature: <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the foNowing declarations: (CHECK ONE) <br /> I have and will maintain a cerMicate of consent to self-Insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> " I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> .__ for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carver and policy numbers are: <br /> Carrier: ( !X4 l CI Gl T Policy Number. <br /> 1 certify,that in the performance of the work for which this permit is issued,I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: ' I I C' Signature: Lt- <br /> Printed Name: f a /L �L'Cc..(j C G,l <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.1 IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LAWR CODE <br /> AUTHORIZAT(hON FOR OTHER THAN C-57 SIGNING PERMIT APPUCATION <br /> (signature oIC-87 licensed autluxtmd repo wentative), <br /> hereby auttwriza(print nems) 1�C- _. �.�"1 rC a E'l <br /> to sign this San Joaquin County Well Permit Application on my lf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> &29-021 MI <br /> FHD 29.02-001 <br /> 6=104 <br />