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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: �j I <br />LfCENSED CdNTF <br />I�� 1 PERMIT SR #: <br />ACTORS 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 <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 />Labor Code. for the performance of the work for which this permit is issued. My workers' <br />coens tloNik_x� <br />surance carrier and policy numbers are: <br />Carrier: Y l / Policy #: � IZu) Exp. Date: <br />I certify that in the performance of the wor -fo-r 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 become subject to workers' compensation provisions oT$ection 3700 of the Labor Code. I shall <br />h forthwith omply with those prcksions. <br />Signature: <br />4A <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPOB'ATION 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 />UTHORI TI FOR OTHER THAN C-57 SIGNING PERMIT APPLICA ON <br />her by aut ze �CJ6 <br />ame nl C- Licensetl Autftorize0 eDresentative �/ rant Name o/ Authonzer0iint <br />to sign this San Joaquin County We & Boring P in Adplication my behalf. I understand this <br />authorization is valid for one ear nd is limi ed to the ork p an date on the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />