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V. ► <br />31 <br />Ice <br />Box <br />Sac <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: Y�� �L 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 California Business and Professions Code and my license is in full force and effect. <br />'\) A,\.)o �,D <br />Contractor Name <br />OJI License #: <br />Signature: <br />ITE Print Name <br />-obe <br />te: <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 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 pen atio 'nsurance carrier and policy numbers are: <br />Tu Carrier:k 4 Policy #: C) I Lc/ --)L -2-17 Exp. Date: I <br />ime <br />5O I n r.. ih ni .n the nrfnrmnnne nF the V I Fns uihinh Fh�n nrw+ii 'n .nn. Berl I nh011 nni nm In.. nn crcnn in <br />1 l.iGl Uly UIQI 11I UIc VVI IOU IIiG UI II IG vYVln 101 VVI IMI LI 110 PCItIa IaOUVU, 1 JIIQII Wl GIII�IVy 011y �GIaVl1 III <br />5' any manner so as to become subject to f e workers' compensation law of California, and agree that if I <br />ubv, should become subject to worke ' comgensation provisions of Sectipr4-3700 of the Labor Code, I shall <br />et hwith comply with those pro v ns. <br />Signature: <br />Print Name: I i 1 LA G <br />WARNING: FAILURE TO SECURE WORKERS' Ompi,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 />MI MS <br />to sign this San Joaquin <br />authorization is valid for one <br />EHD 29-01 6-23-2015 <br />R OTHER THAN C-57 SIGNIh <br />hereb uthorize <br />my e & Boring P rmi Applic96 <br />and is li ni d to th wo plan bat <br />my behalf. I understand this <br />the front page of this application. <br />Site Mitigation Well Permit Application <br />