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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: <br /> 2417 West Lane, Stockton, CA 95205 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: Environmental Control Associates Inc. <br /> 0/ 13 <br /> 695970 Expiration Date: u zoi f5 <br /> License#: � <br /> Signature: ! c �� Title: IV S <br /> Print Name: ' r 'I e l <br /> Date: 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 /> C3 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 /> C)2-- 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: 476VC FDrJ D' Policy#: l R 7Z0 46 -(S Exp. Date: S r ZO(s <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: t� <br /> WUL, AND SHALL <br /> WARNING: SUIBJECT ANS <br /> SEMPLOYER TOE <br /> CRIM NALEPENALT ES AND CIVIL FINESNSATION COVERAGE IS A PFTO $00,000, IN <br /> ADDAS PROVIDED TO THE COST OF COMPENSATION, EST, ATTORNEY'S FEES, AND DAMAGES <br /> FOR N SECTION 370E OF THE LABOR <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I �M+--1- lL� , hereby authorize <br /> rysifF p5) enx /NMfIx PprtsenWM <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 /> s, M. <br /> Site Mitigation Well Permit Application <br /> EHD 29-01 6-23-2015 <br /> I <br />