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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: �� I 'J� PERMIT SR #: <br />4 <br />LICENSED CONTRALTO S DECLARATION <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 />Vvtc <br />Contractor Name: 41 , I <br />License #: <br />L Expirat Date: 1 7 <br />n� 0. - <br />Signature: Title: <br />Print Name: �I y Date: <br />WORKERS' COM PEN SAT N 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 />13 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 />77Vrs do urance c rier and policy numbers are: <br />,i / <br />Carrier: � Policy #: Cl Exp. Date: / <br />1 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 su ject tow ers' compe sation provisions of Seco n 3 00 of the Labor Code, I shall <br />forthwith c mply wiPh those provisions. <br />Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COM NSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMI PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />UTHORI ATION FOR OTHER THAN C-57 SIGNING. RM APPLICATION l,� i <br />�,�� �L�'� ,hereby authorize <br />to sign this San Joaquin Count ell oring P mit Application on m ehalf. I understand this <br />authorization is valid for on y rand i$ limit tot work plan dated on the f nt page of this application. <br />1 <br />ign re of C-57 Licensed uth R ntltive <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />