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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS : 1323 W. Charter Way , Stockton , CA 95206 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 : <br /> License # : Expiration Date : <br /> Signature : Title : <br /> Print Name : Date : <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 /> X 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 # : 9087349 - 19 Exp . Date : 01 /31 /2020 <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 : Gregory P . Wt <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 , , 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 8- 1 -2017 Site Mitigation Well/Boring Permit Application <br />