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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: - 17950Shideler Parkway, Lathrop, CA 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: Gregz V/',( &n k / <br /> License#: CS 7 `0 Expiration Date: ql,- D ! 2D <br /> Signature _— Title: up Crfic/ll 1774wge <br /> Print Name. GGj�! �U��l Date: h Z//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 /> ® 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 /> 13 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: ..T LT Age—w/!, Policy #:INC- o 23�S 39/-O/ Exp. Date: 96;,///9 <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 __Chvcr-Prru�el <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 /> C/7r4l fk^ of hereby authorize <br /> -- - - <br /> Nwm <br /> of C.67 LkanaW Auttwruad Rapnaaotatwe pont Name of AUMoriud Avant <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 /> SignMun of C-67 Llaanaad Authori:an Raprocantativa <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />