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0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 93Lf) E e cd,4 2TZ- wl�y <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 andProfessionsCode and my license is in full forceand effect. <br /> Contractor Name: <br /> License#: �, S� U Expiration Date: <br /> Signature: -7� /, Title: �J -9 <br /> Print Name: t1�Y� tv e.!-' Date: g I 1 0�/S <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 /> CI 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: 5-TK-Tc, FoµUPolicy#: 19 6 Zo9 7-zols Exp. Date: 6-/3/16 <br /> 1 certify that in the performance of the work for which this permit is issued, 1 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: C 1— <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 /> _ ( �' C�1sev� <br /> i, P-_, hereby authorize (}� _ <br /> Nime of e3�.J RUO,onvE Repnien411w Prinl Name OI<ulao,IteO Pgam <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 /> 7an <br /> sa�++ +oie3i ucrosea a�mom.a e.orn.nn�.. <br /> EHD 29-Ul 6-232015 Site Mitigation Well Permit Application <br />