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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 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 #: 938110 Expiration Date: 9 /30 /19 <br />BryanSignature: Cook <br />Napa., ognod try by. Cook <br />cr-trran Cook. oil), amool-tmoio)cos.or-mv com <br />Woe 101 ill, Ds 121425 5.1.00' Title: Project Manager <br />Print Name: Kenneth B. Cook <br />Date: 11/9/18 <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 />0 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 />CI 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 Attached Policy #: Exp. Date: <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 subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />BryanSignature: Cook <br />Digitally signed by Bryan Cook <br />ON: cn--Bryan Cook, o=CDLP, on. ernail=bcookkacascade-env.corn, <br />Date 2018.11.09 I 2:24:51 -0800' <br />Print Name: Kenneth B. Cook <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 />Kenneth B. Cook , hereby authorize Michael L. McLeod <br />Name of C-57 Licensed manora.a Representatrve Print Name of Authortzed Agent <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 />Bryan Cook DSlkofly uoned by 19.yan Cod <br />ON' an.illyw Cook ooOLP o ernall=bco-akecesuale-enytorn, c-OS <br />Date 201.1,09 1215.19 {COO <br />Signature of C-57 Lrcensed Authorized Representative <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application