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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />PERMIT SR # <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 #:-fcS'f,-� E xp Date: % / G - <br />Date: k� ' Contractor: Cce- ` <br />Signature: Title:�`�/t�/�/1��7-- <br />Print Name:_ ----- <br />:1 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 forworkers': compensation, 'as <br />provided -for. by Section 3700 of the Labor Code, for the performance_ of..the work for whid.h Abis <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 carrier an d policy numbers are: <br />Carrier: PolicyNumber: �f0 <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, <br />and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br />the Labor Code, I shall forthwith comply with those pro ' i r► _ <br />Exp: Date: � t �.__ Signature: <br />�� °° <br />�OE2'1 <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS` COMPENSATION COVERAGE.IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CML FINES UP TO $100,000, IN ADDMON TO THE COST OF COMPENSATION. INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. . <br />d�T FAU01 R OTHER THAN C-67 SIGNING PERMIT APPLICATION <br />I, (signature of C-57 licensed authorized representative), <br />hereby auth raze (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 worts <br />plan dated on the front page of this application. <br />EHD 28-01 07MO WELL PERMIT APP <br />