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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 31`0 f.,, ste'r.'rrt Rd (south cf Paradise Road) 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: G/B�,i QJFr <br /> License#: 7 {� ' � Expiration Date: <br /> Signature. _-- ,� -�- Title: <br /> Print Name: G�.d'!/v PG�fI e- _ - Date: ���A <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 /> 0 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: ?el•.' Policy#A1CWa1aV1C( j Exp. Date: /l/ <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 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:__= T ` <br /> Print Name: G'r//"J /'"�i"7c% <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 /> hereby authorize hristopher Stouffer <br /> Name of C77 LkentnJ Aulhanrod Nnprnrrvrlahre <br /> to sign this San Joaquin County Well& 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 /> gipnahrn ef�1 Anlhery _.-(efrtr�4nrv.. <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />