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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 2-12.5 S. k—VW5V- SA(.K.tArnC- M 9-C-4, PERMIT SR #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that l am licensed under the provisions of Chapter 9 (commencing with Section 7000) o' <br />Division 3 of the alifo ni usiness and Professions Code and my license is in full force and effect. <br />Contractor Name: V A"% o G, , 14Y, . <br />License #: U Expir 'on Date: <br />Signature: �\ Title: <br />Print Name: �� �� j Date: r� 7) <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 />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 />111n p en ation ' irance c mer and policy numbers are: <br />Carrier: 6 j Policy #:�� Exp. Date: I / / <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 becomes ect to the rs' compensation law of California, and agree that if I <br />should becomes ject to rker ' compen .atio provisions of Section 3700 of the Labor Code, I shall <br />f rthwith comply ith those provisions. <br />In tv� A - ' I <br />Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' CCWPrENSATION 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 />UTHORIZATION FOR OTHER THAN C-57 SIGNIN P RMIT APPLICATION <br />i,V-1 R x y�11 _� here autthprize o <br />to sign this San Joaquin County -We" Boring P4 <br />authorization is valid for one ykarand is limited to the <br />lichtion 4 my behalf. I under4Aand this <br />n dated ot the front page of this application. <br />EHQ 29-01 6-23-2015 Site Mitigation Well Permit Application <br />