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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: �v �--` r 1 PERMIT SR #: <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 Californiali1NNVVVA <br />BuusinessandProfessiions Code and my license is in full force and effect. <br />Contractor Name: G W <br />License #: Expira ion Date <br />Signature: �, Title: <br />Print Name: r� _ (1 j Date: 0,1 %-0 <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 />compensaion urance carrier and policy numbers are: <br />Carrier: � �vA Policy #: 1�6N�— I Exp. Date: I V 0 <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 ffhe workers' comp ation law of California, and agree that if I <br />should become subject to workers' comwy <br />on provisii ns f Section 3700 of the Labor Code, I shall <br />forthwitwith those rovisions. <br />Signature: 1 <br />Print Name: W 1 V— - �rbl - -_ - - --- - <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 />THORIZATION FOR OTHER THAN C-57 SIGNIN <br />hereby authorize <br />Name of C-57 t. censed Authorized Representative <br />to sign this San Joaquin Coun Well & BorinPermit Applic; <br />authorization is valid for one y ar and is it(e�dt�o() a workplan d <br />ME <br />Ion my behalf. I understand this <br />on the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />