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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 23577 S.Mountain House Parkway, PERMIT WP #: <br /> �ra�y,eA�sae4 <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: TERRACON CONSULTANTS INC <br /> s69004 Ex iration Date: 05-31-21 <br /> License #: p M <br /> Signature: /' Title: Environmental Dept.Manager <br /> fj November 13,2019 <br /> Print Name: Tony Mikacich 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 /> 0 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 /> -21' Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy nUm zLo1o337-1s-s1-K <br /> Carrier: TRAVLERS INDEMNITY COMPANY Policy#: TC21KUB131.1374217 Exp. Date:01/01/2020 <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 /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: Tony Mikacic <br /> tf <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 /> F1 hereby authorize /O?v /A:f'14 C.IC <br /> LotC Lkeneetl AufhoNzetl Repmm�...... P INeme or Au@oticed Agent <br /> to sign tir 1is San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one year and is limited to�he work plan dated on the front page of this application. <br /> ' SlgneWrt of F5I Llcensetl AolhoNed Represenle0ve <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br /> I <br />