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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> APN:221-210-020,Manteca, CA 95336 <br /> JOB ADDRESS: 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: Woodward Drilling <br /> License#: 710079 Expiration Date: �1 - 9 k- (-I <br /> Signature: �n/iy Title: ak1j. tuf' <br /> Print Name: 1.cy-y-�6y , E. 1�b� yd 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 /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> /compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:/I)SltyWet . 9-T k Policy#: 00, /285-2089 Exp. Date: /0% 7 <br /> e PA <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: <br /> Print Name: Lplrt !t lq E l�bc�lAxtYd <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 /> I, hereby authorize <br /> to sign this San Joaquin County Well S 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 /> EHD 2"16-23-2015 SM1e Wtpabw WON Pa and Apphcalan <br />