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1 <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:-_ ,� �" 11th;Sfr2z t //"�Ctrl= PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Sedion 7000)of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name:_-Aeccxt pf,Vvllq 'InC, <br /> License#,- QD�g Expiration Date: W3riNtr) <br /> Signature: _Title:_ PfT L_ ►TQC µA1rlU�gpf <br /> Print Name: 18 Greeff _ Date:_ 1122 j 11 <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: Q <br /> Carrier. Wesko I�SU�an�¢�. Policy#:WWC-3axV7(0 Exp.Date: p o� <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 work 'compensation law of California,and agree that it I <br /> should become subject to workers'compen n provisions of Section 3700 of the Labor Code,I shall <br /> forthw' mply with those provisions. <br /> Signature: <br /> _ZA" <br /> Print Name: % 6f t <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,ATTORNEYS FEES,AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 8706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PE - 1I1 APPLICATION <br /> i,x—G�Ia� t7f ttr\ hereby authofte..FazkpIT� yn- &ryeaNg20- i <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 pla ated on the front page of this application. <br /> EHO 2"18.73,2015 Site Mitigation Well Permit Application <br />