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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ' h 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 Name: <br /> License #: Q Expiration Date: do <br /> Signature: ViNvu Title: <br /> Print Name: VLDate: <br /> WORKERS' COMPENSATION 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 /> INC Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> CompE!nsatio�Zl <br /> ance c rrier and policy numbers are: <br /> Carrier: <br /> iJ G <br /> Carrier: Itog � Policy #: qv Exp. Date: !� j <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 tgthe workers' 9 pensation law of California. and agree that if I <br /> should become subject to workers' mpensation pr visi ns of Section 3700 of the Labor Code. I shall <br /> i forth ith omplly wi t se provisions. <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 /> 1UTH0R1Z4TJON FOR OTHER THAN—C-57 SIGNING PER IT' APPLICATION <br /> rr�_,I, 1 reby�uthoriz <br /> e of G6 Lic enaen Aulhori tl R prasentahve Print Name of AuthonTeA Again i <br /> to sign this San Joaquin C un�W I Boring rmkApplication o my behalf. I understand this <br /> authorization is valid for o e ar .is i ited to the or plan dated the front page of this application. <br /> I <br /> Signatum of C ce mho epresentat.- <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />