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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 471 Ca-f"'I o0oe— AA-46 VA.'I"^-) &42-4. PERMIT SR #: <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 Name: r �'`zTl� �Y �� 72��'��t ,r'`�e- <br /> -- - - - - -- -- - - 11 <br /> License #: _ Expiration/Date: l 3 p 6 2c.�Z 1 _ <br /> Signature: ATitIe <br /> "Print Name: AMR /IG+�R _ ate /)I <br /> % <br /> WORKER ' 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 /> 0 Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carver and policy numbers are: <br /> Carrier: &M4W -Policy#: G�59� _:a �9 exp. Date: D <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 orkers' compensation provisions of Section 3700 of the Labor Code. I shall <br /> hwith comply with those provisions. <br /> Signature: _ <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' MPENSATION 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 /> AUTIHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize 1.114va l e fc a.�,.-d✓j1 <br /> Nam o� um�C UgrasE Fopmcm/alnA9^ <br /> to sign this San Joaquin County Well oring Permit Application on my behalf. I understand this <br /> authorization is valid for one year and is firnite44c, the work plan dated on the front page of this application. <br /> - a- —. <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />