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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: C U` �%�� C �� PERMIT SR #: <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 <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 />compensation surance carrier and policy numbers are: <br />Carrier: �,, % Policy #: -7 Exp. Date: / <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 worker co�pensation law of California. and agree that if I <br />should become subject to workers' pensation rovi Ions of Secti700 of the Labor Code. I shall <br />fo w h comply ith those provisions / <br />Signature: D <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPEN 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 />to sign this San Joaquin County <br />authorization is valid for one vear%anc <br />N C-57 SIGNING PERMIT APPLICATI <br />�I , hereby a <br />8 ring Permitpplicon on my eha . I understand this <br />o the work Nayrdatqd on t46fron page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />