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+ h <br /> e ---- '� — WELL PERMIT APP - <br /> EHE 2"l 0712Df16 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPUCATION SUPPLEMENTAL <br /> rJOBDDRESS: 116y iA/ YDSFM /`F AVENME _PERMIT SR# <br /> /L1A1VTE" QA 9533 '7 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that l 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#: C A S 7 A 8 </65 Exp Date: / &t 11 <br /> Date: Z Contractor. to/E <br /> Signature: / Title: /9 p/7oac� <br /> Print Name: �Y//�,k- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereb affirm under penalty.of perjury one of the following declarations(check one) <br /> have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> 77provided 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 tam <br /> er and policy numbers are: <br /> Carrier. Po{icy Number. <br /> I certify that in the performance of the work for which-this permitts issued, I shall not employ any <br /> person in any manner so as to became subject to the wodcers'compensation law of California,and <br /> agree that =1 should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I/121 <br /> shall forthwith comply with those provisiD <br /> Exp. Date: 0/3///Z . Signature: <br /> Print Name: C417 <br /> WARNING:FAILURE TO SECURE WORKERS`COMPENSATIORCOVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO$700.000,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 /> O TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> !, ry+-ryr` .(signature of C-67 licensed authorized representative), - <br /> hereby authorize(print name) 89LF-W Y/FQ0 to <br /> sign this San Joaquin C ounty Well&Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and Is limited to the work ptan.dated on the front page of this application. <br /> ENDnM 07MID YdELLPERWAPP <br />