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0 0 RECEIVED <br /> San Joaquin County Environmental Health Department <br /> JUN 3 0 2016 <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL ENVIRONMENTAL <br /> C i*+-y R►'*)6� -o P. 6P-A—/ N t4, HEALTH DEPARTMENT <br /> JOB ADDRESS: y,?Q (Ai. lOSFp";-}C tQ✓� . PERMIT SR#: <br /> MA v-MC,-1 t C <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: R d�A/T£D <br /> License#: AP77 Expiration Date: <br /> Signature: Title: ,l^AA-e A G t--- <br /> Print Name: C'v v)/ A, Date: o � � 1 \p <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:-1?4VdX4' PRpPJr-r' Policy#: ���C(-y207/o0 <br /> Exp. Date: <br /> p 7 Za �p <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: J. v <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 /> hereby authorize <br /> Name of C-57 Licensed Authorized Representative Print Name of Authorized Agent <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 /> Signature of C-57 Licensed Authorized Representative <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />