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• 0 <br /> San Joaquin County Environmental Health Department <br /> WELL He BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 19800 west Schulte Road, Tracy, CA 95377 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: Environmental Control Associates, Inc. <br /> License#: 695970 Expiration Date: 9/30/2018 <br /> Signature:_' y(�— _ __Title: Owner <br /> Print Name: Tim Tyler Date: 6/12/2018_ _ <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 /> 13 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 /> EI 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: State Fund Policy#: 1.972096-18 Exp.Date: 5/l/2019-- <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 /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: Tim Tyler <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, Tim Tvler hereby authorize Nathan Maroon <br /> rvume of­1 LlunaeU AulnMzed RePreeenlallve 1 m.of A � A9ont <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 /> - —��_slena Pf c-sr ucen.oa mm�onz.e ReP•.aonzmro. <br /> EHD 29-01 8-1-2017 Site Mitigation WeNBoring Permit Application <br />