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i <br />Sari Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: U�II �[i----PERMITWP#: <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 ralifornia Business and Professions Code and my license is in full force and effect. <br />Contractor �Name: � <br />VA-- - <br />License #: >) 161. I�gn \ U % Expi <br />Signature: aA i Title: <br />Print Name: V I Date <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 />c mpens. 1 n insurnce carrier and policy numbers are: <br />Carrier: -- Policy #: G - M- Exp. Date: <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 Co the workers' compensation law of California, and agree that if l <br />should become subject to workers' compensation p``((ovisions of Section 3700 of the Labor Code, i shall <br />t J L C) forthAth comply with those provisions. <br />Signature: <br />Print Name: VA it h <br />WARNING: FAILURE TO SECURE WORK5R$'_¢OMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TC CRIMINAL PENALTIES AND CIVIL FINES UP TO -5100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 370E OF THE LABOR CODE <br />AWHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, hereby authorize T <br />H LI[en�od orhM Roproeen pv� int I Prfmnn o-iAw�irr� A.7nnt <br />on <br />� <br />to sign this San Joaquin ounty ell.& Borin Permit Applicatibn my behalf. I understand this <br />� <br />authorization is valid for on pp ar a d is I" ited to tt e w9rk plan da�gd on the front page of this application. <br />�� <br />EHD 29-01 6-1-201 i <br />Site Mitigation Well/Boring Pemift Application <br />