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San Joaquin County Environmental Health Department WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: �� , PERMIT SR M LICENSED CONTRACTORS DECLARATION I hereby affirm that i am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my iicenca is in fi ill fni-r'A anri affor-+ Contractor License #: Signature: Print Nam( I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as 13 provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' cocnpensatq ' surance carrier and policy numbers are: Carrier: V Policy #: �" �)7 2�— Exp. Date: I certify that in the performance of the work for w ' this permit is issued, I shall not employ any person in any manner so as to become subject to the w rkers) compensation -few of California, and agree that if I should become subject to workers' compensation ovisions of Sectio 3700 of the Labor Code, I shall rthwith comply with those provisions Signature: Print Name: WARNING: FAILURE TO SECURE WORKERS' CDR*ENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT! AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHO IZATION Ft to sign this San Joaquin authorization is valid for one EHD 29-016-23-2015 C-57 , hereby W4 Well & Boring Permit and is lim' t'on the worl t IT ication on my bhalf. I dnderstand this i dated on the ront pa of this application. Mud" Site Mitigation Well Permit Application