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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: I % PERMIT SR #: <br />4'E'Q('E9'68NTRAQT0RS DECLARATION <br />I hereby affirm that I am licensed under, the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of th C lifornia, usi ess a Professions Code and my license is in full force and effect. <br />Contractor Name: <br />License #: Expiratio ate: i L <br />Signature: L Title: <br />Print Name: 11 ,�� I %) l Date: I, I :—;x, _I <br />WORKERS' COLAONSATION 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 ve and will maintain workers' compensation insurance, as required by Section 3700 of the <br />I� ab, r Code, for the performance of the work for which this permit is issued. My workers' <br />or}'tpe satin I surance car ier and policy numbers are: <br />Carrier:1i 0. 1, X Policy #: G 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 subje to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />`l i' forthwith comply witl'i those provisions. <br />Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' CO PENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO c"iNAL 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 />to sign this San Joaquin <br />authorization is valid for one <br />R OTHER <br />Well <br />AP <br />, hereby authorize <br />-ing,Permit Application on My behalf. I understand this <br />to the w¢rkRian dated on the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />