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0 <br /> 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 17100 Murphy Parkway, Lathrop, CA 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 Business and Professions Code and my license is in full force and effect. <br /> Contractor(dame: Advanced GeoEnviron mental, Inc. <br /> License#: 680227 Expiration Date: 1112017 <br /> Signature: 0A ,� Title: geologist <br /> Print Name: William Little Date,08/01/2017 <br /> WORKERS' COMPENSATION DECLARATION <br /> 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 /> 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 /> 0 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: Travelers Policy#: UB3338T982 Exp. Date: 10117/2017 <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: William Little <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, 1N <br /> ADDITION TO THE COSI"OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize <br /> Name of C-67 Ucensgd AilharizedReptesentaNve Pftt Name et Auttrorl nt <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 /> 51Qnatwe of C-U Ucensed AwtMoizedRepresenlative <br /> EHD 29-018-1-2017 Site Mitigation WeWBoring Permit Application <br />