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San Joaquin County Environmental Health Department <br /> WELL E30RING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 3150 ;? Sref,art Rd (South of P, PERMIT SR#: <br /> LICENSED CONTRACTORS 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 Name: California Push Technologies, Inc. <br /> License#: 8848127 Expiration Date: <br /> Signature: _ Title:_Iz7 si; <br /> Print Name: Date:` — -- ---Date: ( ?C / 7 — <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check ane) <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 /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Sit CtJ.�t^.�,<< , -��,u( Policy#: I , r=( it Exp. Date: (L' 7- z�/ <br /> 1 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 workers' compensation law of California, and agree that if I <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> �-�J r},1 ;s c?;h� Stouffer <br /> I, �� � � v , �� hereby authorize. _- --- — <br /> — > o c-57 t¢.n..a wuon a ..tki_ —- M h. of AUVMMaa fysm <br /> to sign this San Joaquin County Well 8: Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br /> Sipnriuro�3tilc[ufsQ1WC zN HProH�tacvc <br /> EHD 29-01 6-23-2015 Site Mitigation Well Pem�it Application <br />