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Sari Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 3OD2 W. 1(_F TTL S:M" LAt-1�E PERMIT SR #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) o` <br />Division 3 of the galifokni4.�usiness and Professions Code and my license is in full force and effect. <br />Contractor Name: Vkj � r✓ <br />License #: % cxpir on Date: <br />Signature: I�� Title: <br />Print Name: j Date: �} <br />WORKERS' COMPS SATION DECLARATION <br />I hereby affirm under penalty of perjury are of the following declaratiors: (check one) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation.. as <br />E3 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 v�crkers' compensation insurance, as required by Section 3700 of the <br />Labor Code, for the pe-fcrrnance of the work for which the permi* is issued. My workers' <br />enation ' urance c mer and policy numbers are. ) <br />Carrier: Policy #:-- Exp. Date: Icy 1 lle,-_ <br />�P , qteQ9_7 <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 51Aect to the rs' compensation law of California, and agree that if I <br />should becomes jest to wdrker ' compensatio provisions of Section 3700 of the Labor Code, I shall <br />f6rthwith cainply •ith those provisions. <br />ID 0) - I <br />Signature: <br />Print Name: 1( IAX 1 ( <br />WARNING: FAILURE TO SECURE WORKERS' CCiJfg=-NSATION 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 FO <br />I, u <br />HAN C-57 SIGNING P <br />, heretty au <br />to sign this San Joaquin ounty-w Boring Permit pli <br />authorization is valid for one y arend i li ted to the or Ian <br />T <br />my behalf. I unde'r4Rand this <br />the front page of this application. <br />EHD 29-01 6-23-2C15 Site Mitigation Well Permit Application <br />