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HcOEIVE <br /> MAR 31 2016 <br /> San Joaquin County Environmental Health Department p� I� <br /> WELL Sr BORING PERMIT APPLICATION SUPPLEMENTALENVIRONMENTAL. <br /> HEALTH nF0aRTk0ck1T <br /> JOB ADDRESS: spa.. � PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I ho;ehy 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 /> Contractor Name: �—�� {��;W <br /> License#: r— Expiration Date: cc/I3/A/8' <br /> Signature: Title: ///G/2opEY— <br /> Print Name: ��/� /'G//�Bl Date: <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 far workers'compensation, as <br /> 13 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 /> M 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: Policy#: /416110/0 t/ISGZExp. Date: e / /16- <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 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 /> f9rthwithh ply with those provisions. <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 3700 OF THE LABOR CODE <br /> ALITI-10131ZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> OO <br /> hereby authorize <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.I understand this <br /> authorization is valid for one year and is limited to the work plan dated on the front page of this application.Ir,n wvw T�Y•,ov <br /> EHD 29-016-23-2015 Site Mltlgallon Well Penft Appllcallon <br />