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San Joaquin County rrrvironmentai liealtb Department <br /> WELL& BORING PERMA'T APPLlCA TION SUPPLEMENiTAL <br /> JOE ADDRESS:2222 and 2244 S.Airport Waw Stockton CA, 95202 PERT t+SR <br /> OCENSED CONTRACTORS ORS DEC:LARA IUVB! <br /> I hereby affirm "hal 1 am Ilcense0 unbet the pruvisions of Cnaapler 9 jcornmencing vi,'Lh Section 7000) Of <br /> Division 3 of the Ca iforn a Business and Professions Code and my license is in rule force arca effect. <br /> Co-,t-ac`.c-Na7ne: VOt Y•Y Dritlilii:. : <br /> License;;. 5_r-7` 4 Exp),rapgri Daatt}e�.11 <br /> L <br /> Sion ature- <br /> Print fvarnP- •l ✓� Date. <br /> VGRKERS' PENUSATION UEOL.ARA m OX <br /> i hereby a,`i irr wider pena;ty of pei jul y C',ie o,L,le 1,0iiuw1`1 1y "folis.. (GheLk uitej <br /> have and v4ti maintai a cpar`ftate to Ee,� cormcen.sat+--n- as <br /> fl provided for by Secuon 3700 of 0 e Lanoi Gooe. for the performance of ine t'.'orK for winch finis <br /> permit is issued. <br /> I have and vn4 mainla!-worxe,s' cc-mensal-!on f S'J'a 'CE. as rec,uired by Secion 3700 of the. <br /> Labor Coae. for the performance of the wo-k cir which tars permi,is issued. nay workers' <br /> cc p nsalion, in, nce c:mpy a .L. PDilcy nUTri^:i <br /> Carrier- - Policy#r: Exp. Date: / <br /> I certify that he performance of the work fQr which this permit is issued, I sha)i not employ any person in <br /> any manner zlc% as 10 tc:=c suti L c lv Lc.)rnp6 iGT i.a"L4 L31 fiornia, Zinn agrGE r of if 1 <br /> should beeorre sub;ec; to 64' +'t2.� G srr: ^' �3r06iS�J 3 �; C=a.� �f.*J G;'?:;ie `ab— CO c, E S.c8+: <br /> Signature: UAW` <br /> —6, <br /> Prnt !dame: -I �� ------- --- <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO MiNAL PENALTIES AND Ci'V L FINES UP TO 5100,000, IN <br /> F4DDITION TO TIE COST. OF CC!ti1PETgS^,T!'3?b, INTEREST, A?TORNEY'S FEES, /SND D'AFAAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> UTH. ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> vc --- -- Py <br /> to sign tl;;s San Joaquin Co . IVDP&8 rirag Pe:m` App: atteam. t understand this <br /> authorization is valid fol an ye anti .sI,sni to tip wvi - pI caort page of this appii�caboti. <br /> .,a:Y..ea t:.7 r..cery tr�.�.mn•.e <br /> EIA 29-01 6-23-2015 5 %litig:;KwiWell neerual Appuaticai <br />