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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: _ffioPERMIT SR #: <br />LICENSED CONTRACTORS DECLARATION <br />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 <br />License #: <br />Signature: <br />Print NamE <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 />y� Labor Code. for the performance of the work for which this permit is issued. My workers' <br />/ \ cpe satl Insuranc carver and policy numbers are: <br />Carrier: A Policy #:q I <br />I Exp. Date: <br />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 becomesubject e work ' compensation law of California. and agree that if I <br />should become subject to workers' ompensation pro isions of Section 3700 of the Labor Code, I shall <br />nfo�rth th comply with ose provisions. <br />Signature: �� n , lE(; ^ <br />Print Name: <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 PERMLT APPLICATION <br />V` , hereb au rizeQwr vv(M <br />Name o/ C-67 Licensetl A onzetl Represenla". Pn ame of Authonzed Ag <br />to sign this San Joaquin Coun ell 8 Boring Per it A plication On <br />y ehalf. I understand this <br />authorization is valid for one yeafanois lied to the w rk plan dated o� front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />