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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: . 4 611(011 t LI f1L (j 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 Narpe: P/, % ISr C1e, Ge o'`GCI iJ l co-) DV i I/ I'l License #: v Expiration Date: 6� 1 3o) I °1 Signature: U 900Z76:;. Title: Akf -f- d rlr,, Ilex Print Name: 3'ay)n cnle, Date: 5/24 Z j Q-, 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 13 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 0 Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: Policy #: Exp. Date: 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 become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Signature: Print Name: 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, J c IA II CO I e , hereby authorize �/� c� a �� s 3d C/1�-J Name of C-57 Licensed Authorized Representative Print Name of Authorized Agent to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization is valid for one year and 's limite--d .{to the work plan dated on the front page of this application. �_L W Signtu are ed Author of C-57 Licensed Reffilisentathre EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application