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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: IN�i � £ 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: Cascade Drilling <br /> License#: 1058336 l/ Expiration Date: 09-30-2021 <br /> Signature: ��cai�r /i Title: Regional Manager <br /> Print Name: Dustin King __ Date: 12-9-2020 <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 /> 13 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:ACE American Insurance Company Policy#'WLRC6780840A(AOS) Exp. Date: 11-01-2021 <br /> 1 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: Dustin Kin <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, Dustin King ,hereby authorize 1--w A1 1019z IQAAItW� <br /> �0G6T LPAI dnl . /YMef4... <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 /> 9 W GAT t n* bM" <br /> E-10 29-018-1-2017 Site Mitigation WelllBoring Permit Application <br />