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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 4239 Pock Lane <br />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 />Contractor Name: <br />License #: Expira ion Da <br />Signature: A, Title: C tJ <br />Print Name: 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 />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 />Ythe <br />, for the performance of the work for which this permit is issued. My workers' <br />on ' urance ca ner and policy numbers are: <br />Carrier: Policy #: Exp. Date: <br />I certify thormance 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 the workers' compensation law of California, and agree that if I <br />should become subject to workers' mpensation prow s of Section 3700 of the Labor Code, I shall <br />o hwith comply with ihoso provisions. <br />Signature: Ax VAI-tj L� <br />Print Name: KIAX I I. V <br />WARNING: FAILURE TO SECURE WORKERS' COMPEN ATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL NALTIES 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 />AUTHORJZA.TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I(A.R, hereb aut orizoted <br />el Sanchez <br />ame o ice sed Auntative not Name of Authorized Agent <br />to sign this San Joaqu n Count Well Boring P rmit Applimy behalf. I understand this <br />authorization is valid for on ye rand is I' i ed to the wo plan the front page of this application. <br />6 PAA tan )iI <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />