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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: III A/1 t/^ d' PERMIT SR #: <br />LICENSED CONTRACTORS 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 />Contractor <br />License #: <br />Signature <br />Print Name <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 />0 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 />C,p(\ Labor Code, for the performance of the work for which this permit is issued. My workers' <br />coom ensa ion innce carr er and policy numbers are: f <br />Carrier: J Z�- Policy #: — 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 "orkers' compensation law of California, and agree that if I <br />should become subject to workers' co pensation provisions of Section 3700 of the Labor Code, I shall <br />forthwit comply with th e p ovisions. <br />Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS"SOMPENSATION 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 />I, 6`I1 J) r U1 V � , hereby authorize Ly" I <br />Nam• C Uun"d Authonud Rapnaantatiw 'nt o1 Authorized Agent <br />to sign this San Joaquin Coun Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid forone y ar and is imited to the work plan dated on the front page of this application. <br />,� @ <br />iynatun o1 C centraduthomab Repm"nil <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />