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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Cq i I CfPERMIT 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 C lifornia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: V�„J <br /> —A-5 <br /> License#: / Expirati aDate:_q.. /Ou <br /> A I- <br /> Signature: Title: <br /> Print Name: ( Date: <br /> WORKERS' COMPEN ATION 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 /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 1 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 /> comp nsation inIsUrance car ler and policy numbers are: <br /> Carrier: Policy#: Exp. Date: �b <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 su ct t the work s' ompensation law of California. and agree that if I <br /> should become subject to work rs' co pensati pr visions of Section 3700 of the Labor Code, I shall <br /> h 'th comply wi those provisions. <br /> n <br /> Signature: <br /> Print Name: <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 /> UTHORI TION FOR OTHER THAN Cf57SIGNING,,PERMTAPPLICATION, <br /> W <br /> 1, � hereby authori e <br /> a can pnsan w <br /> x goof <br /> to sign this San Joaquin Count ell & Boring Permit Applica on my ehalf. I understand this <br /> authorization is valid for one year d is Iimi d o the work plan dated on th front page of this application. <br /> TJ- \,3 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Applicatior <br />