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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1I N -"00AM I4-AJ Aof90 PERMIT SR#: <br /> s To rJs MfJ, t44 CLa6 <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: 6AS6r/49E 401%/L,/,/)V 4 , GP <br /> License A 93 B //O Expiration Date: oq �3° /Z,0 I-+ <br /> Signature: Title: Regional Director <br /> Print Name: Ralph McGahey Date: 6/29/2017 <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 /> E3 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 /> M 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: ACE American Insurance Co. Policy#:WLRC49106075 Exp. Date: 11/01/2017 <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: Ralph McGahey <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 /> 1, Ra h McGahey , hereby authorize RaBe/&r Pyt�L C• E2lGlcS°N <br /> —tea .,,.,..��.. ., w.., <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.1 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 /> EHE 2401 6-23-2015 Site Mitigation Well Permit Application <br />