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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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: CrgL. Forz j(A , t" C <br /> License 565 Expiration Date: 5 3111 <br /> Signature: Title: QZMcv <br /> Print Name: M Date: l ( 1 /15- <br /> WORKERS' <br /> 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 /> 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 insurance carrier and policy numbers are: <br /> Carrier: N AYL-rK0(7-,K> Policy#: -3 Z t✓i< LY` IR -j Exp. Date: 10&// <br /> I cerci#y-tfia#�e-t#� <br /> r <br /> -should become s ubja ct!o as sr-Gede <br /> Signature: <br /> _ Ax�� <br /> Print Name: MvA2tfc - `z C,-C,,f5A <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 /> I, j''1iNaK - ��2pi�Pr(� - , hereby authorize -rJ,,vy �14t_I" l <br /> Name of CST censed Authorized Representative PH nt Name of Authorized Agent <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 rk plan dated on the front page of this application. <br /> 4Z/1A <br /> ign ensed Authors N <br /> epneenletsw <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />