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Title: <br />0 <br />UAL') / Expiration Date: <br />cl.rvuit4/4_46ic aia <br />Date: <br />ontractor Name: <br />License #: <br />Signature: <br />Print Name: <br />San Joaquin County Environmental Health Department <br />WELLI BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: <br /> <br />PERMIT WP #: <br /> <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 an P •fessions Code and my license is in full force and effect <br />WOKERS' 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 />0 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 />Carrierkt:k 6dyi IS1 j!Policy #:1052-2-3 -2,026' Exp. Date: f/- <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 s bject to wor rs' mpensation provisions of Section 3700 of the Labor Code, I shall <br />th comply with those provisions. <br />Signature: <br />Print Name: <br />sS" <br />WARNING: FAILURE TO SECUR WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />SUBJECT AN EMMOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />AS PROVIDED FORM SECTION 3706 OF THE LABOR CODE <br />AUTHORIZATION fOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />( . hereby authorize .n. ourroo of Amthorwitl Aflfl <br />Permit Application on my behalf. I understand this <br />ork plan dated on the front page of this application. <br />S.—Tinsture 0, C <br />C1,0 <br />to sign his San Joaquin County Well 1.3 • <br />authorization is valid for one year and is Urn • the <br />Site Mitigation WelkBoring Permit Application <br />Et-iiD 24-01 -1-2017