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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 its in full force and effect. <br />License #: C.,X S/ Exp Date: <br />Date:f <br />/x5r Contractor: <br />Signature: Title: <br />Print Name: <br />WORKERS' 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 />compensation insuranc/e� carrier and policy numbers are: <br />Carrier: /"(r/ Policy Number: 11f��li0 2%%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', <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 provisions. <br />Exp. Date:/- Signature: .W .�®_i <br />Print Name>`. 4? :r' <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 />AU H0fWATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br />I, fes- (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 <br />ork <br />plan dated on the front page of this application. <br />EHO 29-01 05/09/12 <br />WELL PER4ff1A <br />".3 <br />