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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL r JOB ADDRESS:*LC: J� { PERMfT SR#: SED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. Contractor Name: License#: t-� Expir ' n Date: L Signature: 1 Title: Print Name: Y ( )1 Date: WORKERS' COMPE ATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' cQmpensation ' urance carrier and policy numbers are: Carrier: Polic #: } Y ` c Exp. Date: I certify that in the performance of the wor r w ' ht his permit is issued, I shall not employ any person in any manner so as to become subject to he wor rs' compensation law of California, and agree that if I should become subject to workers' com ensati, n provisi0 Section 3700 of the Labor Code, I shall forthwith ompiy with tho a pr visions. Signature. Print Name: WARNING: FAILURE TO SECURE WORKERS' q0M ENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMI L PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE UITHORIZ 10 FOR OTHER THA --57,SIGNING-PERMITSIGNiNG-PERMIT APPLICATION h reby aut orize Name of C-57 Licensed utborized epmse tativs Pnnt Name of Atrtftorizad Agent to sign this San Joaquin County Well ring ermit�ipplica ion on my behalf. I understand this authorization is valid for one ye an It to th wo plan d ted on the front page of this application. Signa um of CS Kensed uM epmsentatnve EHD 29-01 6-23-2015 Site Mitigation Well Permit Application