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1 A ''Di <br /> EHD 2MI 07l2wlo <br /> WELL PER M rr APP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: lb-11 1204" 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#: 206"7 Exp Date: 11/3,1? <br /> Date: G ,✓ Contractor: pGiel—o/r- <br /> jk',>;'„� <br /> Signature: _3w Title: Gam, <br /> Print Name: Tva �t/,vyg=n <br /> r� WORKERS' COMPENSATION DECLARATION <br /> r : <br /> C' I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> Cr- <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> fi provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> y- 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: 5f0-1e. Fr/,?" Policy Number: SY/?3 it i <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 to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compens ion provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those pro�ion�� <br /> Exp. Date: 1 Z Signature: <br /> Print Name: 'Tua— N4VyG^ <br /> v <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. 1 V'`^ yL� (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) A/4--,40-1 S to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. l understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHO 29-01 07/20tio WELL PERMIT APP <br />