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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1102 W. Kettleinan Ln, Lodi, CA 95240 PERMIT WP #: <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 California Business and Professions Code and my license is in full force and effect. <br />r,. <br />Contractor Name: 66 �A\mA� <br />J! �License #: �� Expira on Date: L' <br />rlt 1 <br />Signature: r� Title: (� <br />Print Name: U��i( 11 I,� Date: <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 />compenkafir insuran e carrier and policy nu ers are: I <br />Carrier: '' Policy #: k�(� Exp. Date: j / <br />I certify that in the performance of the wofo which this permit is issued. I shall not employ any person in <br />any manner so as to become subject td the orkers' compe tion law of California, and agree that if I <br />should become subject to workers' com ens�tion provisio s of ection 3700 of the Labor Code. I shall <br />forthwith mp�y with tho pr isions. <br />Signature: <br />Print Name: <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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I'-- < I K a I 1V� C', ereby uthoriz Brunch 11. Ft:l <br />Name of G57 Lhor etl presentative Pont Name of Authonzetl Agent <br />to sign this San Joaquin County Viiiill & Bort g Permit Appiicati n on my behalf. I understand this <br />authorization is valid for one ar and is -mited to he work plan dat d on the front page of this application. <br />�nature of G57 License t zetl R pres tat.ve <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />