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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1252 Stanislaus St.,also known as 702N,Aurora,Street,StocktonPERMIT 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 California Business and Professions Code and my license is in full force and effect. <br /> License#: c57 720904 Exp Date: 4/30114 <br /> Date: \� 2D t 1Contractor: v&w Drilling,Inc. <br /> Signature. Title: :2afsduk— <br /> Print <br /> Name: xarli string <br /> RKERV 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 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 for which this permit is issued. My workers' <br /> compens ti ins ranc rrier an policy numbers are: <br /> Carrier: Policy Number: <br /> I certify that in the performance of the work for which this permit is i ued, I shall not employ any <br /> person in any manner so as to become subject to the orkers' comp nsation law of California, <br /> and agree that if I should become subject to workers' com nsation pro ision o Section 3700 of <br /> the Lab Cod , I shall forthwith comply with those pro io <br /> Exp. Date:_1 Signa ` <br /> Print Name: Y D� <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SI IS 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 A GES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> TH <br /> A ATIO F OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to sign 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 /> EHD 29-01 05/09/12 WELL PERMIT APP <br />