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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: rb A MV� 00,1196-1, 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: (7ub&- <br /> License#: JIdS-1 w Expiration Date: 31//f, <br /> Signature: _Title: <br /> Print Name: �, l Z �Q 2� a.t (! esti, Date: 7/ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> have wid will maintain a certificate of consent to self-insure for workers'compensation, as <br /> E3 provided for by Section 3700 of the Labor Code,for the performance of the work for which this <br /> permit is issued. <br /> 1 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier:/_ Policy#: At e%{,)O/0y/�4'' Exp. Date: <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 corn ly with those provisions. <br /> Signature: <br /> Print Name: G" ! Oa- <br /> WARNING: <br /> QWARNING: 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 /> I, hereby authorize <br /> ❑•nnori air..,,oril Mdmnu••u N�Vrw••n,•or. Ynn1 M.m.of Avmonm wpn, <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 /> ,rn.l•,n al CO l 1, .j XVllr.rli„�Rry,/I,.IINI . <br /> EHD 29-01 6-23-2015 Site Mltigallon Well Permit Application <br />