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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />,1013, ADDRESS: /a s° L4A'ryi 44 ----- PERMIT WP #: <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 ft: ; { '6 `*� V Expiration Date: <br />Signature:I f �Title: , C5 L &-&aj r j�-u <br />Print Name: I, PN A—r"L '> Date: <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 />provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />M' 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 />compensation insurance carrier and policy numbers are: <br />pt -op 6.tstlaI(y C? x%17 <br />Carrier: T�'ujlPl ot.t >'�mr:<r�HPolicy #: ,� —� ` Exp. Date: J 0/ ,Z,91efr <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 bee subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />C <br />with comply with those provisions. <br />Signature: )/ <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 PERMIT APPLICATION <br />/V PV t L k.t. ItA-y ti , hereby authorize <br />Name of C•57 LicensedWithorized Rapreeem.tWa print 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 onear and is limited to the work plan dated on the front page of this application. <br />e <br />Signature *1 13,17 I.Icensod Authorfzed Representolive <br />EHD 29-018-1-2017 Site Mitigation Well/Boring Permit Application <br />