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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: 11��'1}1 11�Lt"�rL PERMIT SR #: 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: License #: ( 1 CAD Expiration Date: Signature: � Title. Print Name Date: WORKERS' C-6MPENSATION 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 CX Labor Code, for the performance of the work for which this permit is issued. My workers' compensation innce carrr�er and policy numbers are: Carrier: J r-71,. % Policy #: i 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 t�workers' compensation law of California, and agree that if I should become subject to workers' compensation provisio s of Section 3700 of the Labor Code. I shall forthwith comply with those p ovisions. Signature: Print Name: ( V, I I i V t'Jf L WARNING: FAILURE TO SECURE WORKERS''GOMPENSATION 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 RMIT APPLIC hi ��) L hereby authorize tk l.�cenaed Aulhonzetl RepresenW.- I Pnnt Na-- of Amhonceu Agent to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization is valid for one yr ar and is invited to the work plan dated on the front page of this application. Signature of C -S7 �censoo ulhonzel! Reptesenpti EHD 29-01 6-23-2015 Site Mitigation Well Permit Application