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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: '1355 i/`�� N��hw �{ S-toc K--fcn 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 />Division 3 of the California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: V, - <br />License #: 720 Expir ion Dat y3 0 /10 <br />Signature: Title: <br />i <br />Print Name: 1 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 />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 />compensation 'nsurance carrier and policy numbers are: <br />C, <br />Carrier: Policy #: `I 201 I Exp. Date: 1 <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' cc ii1�ensation provisions of Section 3700 of the Labor Code, I shall <br />forth thf comply with those provisions. <br />Signature:,, <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' 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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize OO ,4,n ( „r MPF <br />Name of C-57 Licensed Auth rued Represent ive Print Nam of Authorized Agent <br />to sign this San Joaquin -County Well & Boring Permit Application orgy behalf. I understand this <br />authorization is valid for one ear and i limited <br />tot a work plan dated on the front page of this application. <br />Signature of C417 Uel 7)AuthorizedRepresentative <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />