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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: aj Cf)-- PERMIT SR #: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that l 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: <br /> License#: n, a5q 04 J Expirati Date: lc7u — <br /> Signature: Title: <br /> Print Name: I _.�(rO J In 14 Date: <br /> WORKERS' COMPS 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 /> 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 /> comp nsation i urance car ier and policy numbers are: <br /> Carrier: APolicy #: 11193aExp. Date: 'b <br /> I 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 suct t the workers' ompensation law of California. and agree that if I <br /> should become subject to work rs' co pensatian pr visions of Section 3700 of the Labor Code, I shall <br /> h 'th comply wi those provisions. <br /> Signature: J <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPED ATION 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 C 57--SfGNING.PER PLI .ATION,.-1 <br /> I, here* authori e W <br /> me canes e n ®preysntativa <br /> to sign this San Joaquin Cdpn ell & Baring Perrhit Applica ory y half. I understan this <br /> authorization is valid for one ear d is limi d to thew plan dated op th front page of this application. <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permd Application <br />