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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 2615 Station Drive, Stockton CA 95215 <br />PERMIT WP #: <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 Name: \ I �1' W N'1 t1m/A r 1 nc <br />License #: Expiration Date: �'113G c <br />Signature: Title: �i VGC�� <br />Print Name: Date: e t <br />WORKERS' COM NSAT'QN 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 />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*ssurance carrier and policy numbers are: <br />Carrier: C (, Policy #: I Exp. Date: %V <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 *orkers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisarts of Section 3700 of the Labor Code, I shall <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 />HO <br />N C-57 SIGNING PERMIT APPLI <br />I, (.{,�� Mega" <br />urphy <br />Name of C-57 Licensed Authonzed Representative I `I Pnrt N me of Author.. Apert <br />to sign this San Joaquin Cou ell & ring Permllit Application on my ehalf. I understand this <br />authorization is valid for one lyeao nd is llim�ecj to the wo k plan dated on th ront page of this application. <br />/n.— n \ <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />