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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: qt-,U f Dlz # P,Wer^4 J /6 PERMIT WP#: <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 California Businessand Professions Code and my license is in full force and effect. <br /> Contractor Name: ( 4-,Z/fr.,R L, G <br /> License #: C ,� /d y�l' Expiration Date:—? /3o <br /> Signature: Title: L'y��q�icy�r /y7gs,op� <br /> Print Name: 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 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 /> C 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#: WC O 2 3 S• 3-k/U Exp. Date: .=C1 /-1 l/ <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 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 /> forthwith comply 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 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize <br /> n1lp o1 G57 Llaanwd Aullmdzed RnwcnanmiWe Print Nama of Autharlr,Apum <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. <br /> �J <br /> 319W n o1 G 7 Licane9d kdhanwd Raw_ <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />