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Sa Joaquin Cou ty Environme tal Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 12878 W. McDonald Rd, 95206 <br />PERMIT WP #: <br />LICENS D CONTRACTORS DECLARATION <br />I hereby aff rm that I am I censed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Divis on 3 of the Cal fornix Business and Professions Code and my license s in full force and effect. <br />Con ractor Name: Taber Drilling <br />License #: 969927 <br />Expiration Date: 02.29.2020 <br />Signature: Title: VP /Exploration Coordinator <br />Pr n Name: Brian Young Date: 02.29.2020 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />I have and w II maintain a certificate of consent to self -insure for workers' compensa ion, as <br />❑ provided for by Section 3700 of the Labor Code, for the performance of he work for which th s <br />permit is issued. <br />I have and w II maintain workers' compensation insurance, as required by Sec ion 3 00 of the <br />0 Labor Code, for the performance of the work for which this perm is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: State Fund Policy#: 1972433 Exp. Date: 07.13.2018 <br />I cert fy hat 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 Sect on 3 00 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Print Name: Brian Young <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 />I, Brian Young , hereby authorize Megan Murphy <br />Name of C-57 Licensed Authorized Representative Pri t Name of Authorized Agent <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 work plan dated on the front page of this application. <br />Sig ature of C-57 Licensed Authorized Representative <br />HD 29-01 8-1-20 Site M gat on Well/Boring Perm Application <br />