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9 <br /> FJiD 2901 07120n0 WELL PE:RMITAPP <br /> San Joaquin County Environmental Health Department <br /> 3 <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> J08 ADDRESS: � 2 tF-� t9G{�� � `7 PERIV�Ii SR <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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#: 636387 exp Date: 1-31-2012 <br /> t Date: Contractor: Precision Sampling,Inc. <br /> t Signature: L J, Title: Manager <br /> Print Name: Jim Kleinfelder <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the following declarations:(check one) <br /> I have and wilt maintain a certificate of consent to self-insure for workers'compensation,as <br /> provided for by Section 3700 of the LaborCode,for the performance of the work for which this <br /> permit is Issued, <br /> XX 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: Seabright Ins. Pollcy Number: BB1113866 <br /> 9 <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'compensation provisions of Section 3700 of the <br /> Labor Code,I shall forthwith comply with those provisions. r' <br /> �4 <br /> ' Exp. Date: 6J30i12 Signature: <br /> ' Print Name: iim Kleinfelder <br /> WARNING.,FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE;iS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FiNE.4 UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. (signature of 0.67 licensed authorized representative), <br /> hereby authorize(print name) ,#o <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf, I understand this authorization <br /> Is valid for orae year and Is limited to the work plan dated on the front page of this application, <br /> EHD 29.01.07W110 WELL PERMIT APP <br /> i <br />