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0 i <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 /> ContractorName: C1�Cwc- <br /> License#: `3 10 t 1 0 Expiration Date: <br /> Signature: Title: I)PS MA-kiAG1-'YI,- <br /> Print Name: �C��`� W t�Gil tc1A Date: 0,5/15 ' <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 /> �$ Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: Exp. Date: / <br /> Jit- Polic #: WG 01"434-'t Exp. (01 <br /> Carrier: �o>J 9u, S�-�`�S � I Policy <br /> #: <br /> 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 /> �o th comply wi hose provisions. <br /> Signature: �"`� <br /> Print Name: loot)po A) totl C LC WIC 6, <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 C57 SIGNING PERMIT APPLICATION <br /> Eric Rowne <br /> �LI f Iul t) L 't1�C-1� 1�t�ikhereby authorize_� A <br /> V� <br /> to sign this San Joaquin County Well&Boripg-p#rmit Applica to on my behalf.1 understand this <br /> authorization is valid for onq y r an limited to theZ plan d ted n the front page of this application. <br /> (� 15 [m o <br /> n. <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />