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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 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 Nam�Xt <br />Name: ��`G— T--�' — <br />License #: G,S 7 ��,� ! Expiration Date: <br />Signature: � Title: ZVI <br />/ <br />Print Narne�-- Date:....__....__z--- <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 />1 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 />compensation insurance carrier and policy numbers are: <br />Carrier: _�7— � Policy #:�,(/G(,Z3S',3�/�(j(i 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 to the workers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith con pl with those provisions. <br />Signature: <br />Print Name: y//7-ru��r' <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 />hereby authorize —rV1*11., <br />nv of t,'• ccnee, IlnlparHW HcpI.•cnn,+lirp �hlnl ll,n o 1lUtl1or1IN gaol <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization Is valid for one year and is limited to the w rk plan dated on the front page of this application. <br />—7ai1a II�n1 a ant 11 ton cohtaliY� <br />EFID 29-016-23-2015 Site Mitigation Well Permit Application <br />