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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: i (Pyrf Wi Y, PERMIT WP #: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. Contractor Name: u"r� i� ti c,— 6-1N % N S C V �'� 5 t a., � License #: J '6 Expiration Date: 9 ► Zv I Signature: h �1� Title: 2 ES't Print Name: I t9�- � N !moi LL c ��►'t S Date: `3 3 I WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as ® provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Ptop Cgsdul Ey 6 �l 7 Carrier: %fWle'111 Oi� nieltmPolicy#: (J % �9 Exp. Date: % p/—Zj%� I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, and agree that if I should bee subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall 7 __-----fo—rthwith comply with those provisions. Signature: Print Name: AJ GC, 0A) L -U/ A --,K, s WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION i N (, Vii[L1.1 I, � , •.- r- � .r-• It-AI.hereby authorize � I �- Name of C•51 1.1centradViDthorized Representative Print Nome of Authorized A. of i, .� e to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization is valid for one ear and is limited to the work plan dated on the front page of this application. Signet,- of C•51 Licensed Authorized Representative EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application