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San Joaquin County Environmental Health Department <br />- WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: S I0 W �je 11�� PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Divisign 3 of the Californla Bus ness and Professions Code and my license is in full force and effect. <br />i <br />Contractor Name: U <br />License #: , �,� Expirat' n Dat _ <br />Signature: ��,' �' Title: �� ti�.L <br />Print Name: 1�L�� �1 �r L i �` I Date: <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 />E3 provided for by Section 3700 of the I,,abor 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 />p9pon in urance carrier and policy numbers are: <br />Carrier: . `� Policy #: C�� �- Exp. Date: (, <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisions of Se <br />with comply with ction 3700 of the Labor Code, I shall <br />fo hose provisions. <br />Signature!' � �t, y � � 0-A <br />Print Name: <br />E <br />WARNING: FAILURE TO SECURE WORKER' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />T <br />to sign this San Joaquin <br />authorization is valid for one <br />plication on my b <br />an dated on the fi <br />f. I understand this <br />page of this application. <br />EHE) 29-018-1-20`17 Site Mitigation Well/Boring Permit Application <br />