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JOB ADDRESS: X <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />�1 <br />LICENSED CONTRACTORS <br />PERMIT SR #: <br />TION <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 <br />`and <br />�Professions Code and my license is in full force and effect. <br />Contractor Name: \� �"&D � w1 , ` oc, i i <br />License #: <br />Signature: <br />Print Name. KM I I <br />Expiration Date: L <br />Title: C <br />Date: �7 % <br />WORKERS' GGIVIPENSATION 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 />0 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 />CoMpensainsurance carrier and policy numbers are: <br />Carrier: Policy #: J7 Exp. Date: h ke- <br />I <br />certify that in the performance of the work ff which his permit is issued, I shall not employ any person in <br />any manner so as to become subject to thixworkers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisiop�-q Section 3700 of the Labor Code, I shall <br />orthwith co ply with those pr visions. <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 />AUTHORtZATION FOR OTHER THAN C- <br />�/ <br />I, I 11 �� M A , hereby <br />to sign this San Joaquin Cou <br />authorization is valid for one year <br />EHD 29-01 6-23-2015 <br />II & Boring Per it Apolicatio on <br />lim!" to thew rk p)an dat d on <br />rlrl�,�l� <br />behalf. I understand this <br />front page of this application. <br />Site Mitigation Well Permit Application <br />