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RE"T IVED • <br /> San Joaquin County Environmental Health Department <br /> t ,� U 5 2018 WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> HEEgNVIRONMENTAL <br /> JOB ADDRESS:DEPARTMeT 2�5 t'1/ , �h r C to �W�y PERMIT SR #: <br /> srta e"Grr6 r( <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 alifornia Business and Professions Code and my license is in full force and effect. <br /> IN <br /> Contractor Name: <br /> License#: TkA . Expira ' nDate: <br /> r <br /> Signature: Title: Vin <br /> Print Name: V1 Date: t'✓ 3 <br /> WORKERS' f-rifuLzINISATION 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 /> c pensatio surance carrier and policy numbers are: <br /> Carrier: Policy#: �0(2a Exp. Date: <br /> I certify that in the performance of the work for w c this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the wo er ' compensation law of California, and agree that if I <br /> should become subject to worke/'s)compensati n pr visions of Section 3700 of the Labor Code, I shall <br /> o with comp <br /> o lm/p) wi those provisions. <br /> Signature: V <br /> Print Name: 0 <br /> WARNING: FAILURE TO SECURE WORKou <br /> OMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TOINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST 9 COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECtl N 3706 OF THE LABOR CODE <br /> ,AUTHORdA'TION FOR O T ER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, , hereby authorize <br /> maluv. r� ,m.m,wmahue•e•m <br /> to sign this San Jo mCounty II & ipg Permit Application on my behalf. I understand this <br /> authorization is valid for one e r and i li it <br /> h the work pl da�d on the front page of this application. <br /> gne W i o R ro utln <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />