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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: f r jr� lk Droi <br /> PERMIT WP#: <br /> LICENSED CONTRACTORS ECLARATION <br /> 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 ''// Expiration Date: 10-15-2020 <br /> Signature: ���r �/� Title: Project manager <br /> Print Name: Dustin King Date: 10-15-2020 <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 /> 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: Marsh USA, Inc. Policy#: WLRC65890252 Exp. Date: 11-1-2020 <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 /> c <br /> Print Name: Dustin King <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 <br /> Nm of C-s7 t.ic....d Authorized R.pre Wivn Print Nun.of A4thoriied Agent <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.l 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 /> �� <br /> Sign t—of C3 1-1—d Authorised Repres.nhtive <br /> EHD 29-01 B-1-2017 Site Mitigation Well/Boring Permit Application <br />