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0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 25640 South Schulte Road, Tracy PERMIT WP #: <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: C�� lo/�!�(j e � <br /> License#: C17 t14 Expiration Date: <br /> Signature: •— r^ Title: Qgei"7-7$� �An <br /> Print Name: Gti/'!f /U/7 9' Date: SZj X/7 <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 carrier and policy numbers are: <br /> Carrier: Zcr/iC� j j/ cl"!Cp/J Policy#: 11/C 023538 'Exp. Date: 3 <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: /i er— <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 /> !/-AUTHOg/vR�IIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Pew?w?Gy , hereby authorize Amanda Magee(Stantec Consulting Corporation,Inc.) <br /> N/moN C.q LRmaN nuOp unIWM IfhYm elnWnM1W pM <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 t ork plan on the front page of this application. <br /> sgnnum a c-n trcmeonnnnwune nenA...mna� <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />