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, hereby authorize John Lane of Condor <br />Name 01 CM Licensed Authorized Representative Print Name of Authonzed Agent <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />Kenneth B. Cook <br />• <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRE55:22 Ae( j/d c%kArp /7 - 2 ._520 <br />PERMIT #: <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: se/ 611/rw <br /> <br />License #: <br /> <br />Expiration Date: 9 /30 /19 <br /> <br />Signature: Bryan Cook ONVAly NgNed by Bryan Cook <br />ON En Brydn Cook, 0.,COLP, ou,NNNI bcook aceN.id, env (orCi=iI <br />0.oe 2018 0601 IS 5950 N7 00 Title: Project Manager <br />Kenneth B.Cook Print Name: Date: 5/31/18 <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 />12 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 />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: On File Policy #: 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 comply with those provisions. <br />Signature Bryan Cook Digitally signed by Bryan Cook <br />DM cn=Bryan Cook, o,CDLP.ou, email=bcook@licascadeienv.com,,US <br />Dal, 2018.06.01 11:1915-0)00 <br />Print Name: Kenneth B. Cook <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 />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 />Digitally signed by Bryan Cook <br />Bryan Cook <br />cni-firyan Cook. o=CDLr. ott emad kook liMascade-env om <br />c=US <br />rte..- 20,8 n6n1 15-55 S7 .0r00. <br />Signature 0( 0-87 Licensed Authartz•d Representative <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application