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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ,'b /';; 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 Caldomia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name:__ Die+r�,•,.� � �, , �c <br /> License#: /��Jas _ _ Expiration Date: //3 ill <br /> Signature: -- Title:_ _L <br /> Print Name: (_C+Pi4'L Date: <br /> WORKERS' COMPEivcATION DECLk-,RAT:OaI <br /> I hereby affirm under penalty of pedury one of the following declarations: (check one) <br /> I havo and will maintain a certificate of consent to self-insure for workers'compensation,as <br /> l7 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 /> l� 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: O�9/V Pollcy#: Ar Ca)0 /05/!La Exp. Date: <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 /> forthJ�jhly with those provisions. <br /> Signature: <br /> PrintName: A 4-el, e�- <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 /> AUTIJ0RI2:A IOi� POR OTHER TH!',iN C-57 SIGNING PERI!,iIT APPLICATION <br /> hereby authorize <br /> —fi.i s�3Ti nT—..�iiw,w.a`lF-.pK..,u.i..z— ——__.--••-- ---- -�nw,wm."a�:.no.�su wP, -- <br /> to sign thls San Joaquin County Well d 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 /> ;,.T..a 3i•,ii::.ww3",wii�;,tn:d a.o.-•«ti,.-- <br /> EHO 29-016-23-2015 She MitgUon Well Permit Application <br />