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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 10848 Copperopolis Road, Stockton, CA. PERMIT SR #: <br /> <br />Contractor Name: <br />License #: <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 />Gulf Shore Construction Services, Inc dba GS Exploration <br />Expiration Date: 8/31/17 <br />Signature: Title: Business Office Manager <br />Print Name: <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 0 <br /> <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 />Date: 3/8/17 <br />Carrier: State WC Fund Policy #: Exp. Date: 8 /2 /17 <br />I certify that in the performance of work for which this permit is issued, I shall not employ any person in <br />any manner so as to become ject to the workers' compensation law of California, and agree that if <br />should become subject to or ers' c mpensation provisions of Section 3700 of the Labor Code, I shall <br />ith comply with those provisions. <br />Signature: <br />Print Name: jennife Masse <br />WARNING: FAILURE 0 SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJE 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 />Chad M Walker , hereby authorize Jordan Lewis <br />Name of CV Licensed Authorized RePresed eo Print Name of Authorized Agent <br />to sign this San Joaqui <br />authorization is valid for on <br />ell & Boring3.emili Ap • lic • Ion on my behalf. I understand this <br />mite! WU:- work p n • tred on the front page of this application. <br />id /4 <br />Vature C-5, r <br />R offal a. <br />Site Mitigation Well Permit Application EHD 29-01 6-23-2015