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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />16476 Cohen Road <br />JOB ADDRESS: PERMIT SR #: <br /> <br />LWIS(1E4 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 />Carrier: <br />Signatur <br />Print Name: <br />Contractor Name: gA10 1,e,t Of___ • <br />License #: <br />N-4 <br />I at) <br />Signature: <br />Print Name: <br />WORKERS' Colin <br />ietTION DECLARATION <br /> Expira7 Date: <br />Title: <br />Date: <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 />mliensation inqfurance carrier and policy numbers are: <br />Policy #: 11150,d------;)V Exp. Date: /0// <br />I certify that inithe performance of the wbrk 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 o workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />orthwith comply with those provisions. <br />Ar ik <br />WARNING: FAILURE TO SECURE WORKERaMPENSATION 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 ECTION 3706 OF THE LABOR CODE <br />UTHORIZATION FR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, <br />Name of C-57 Licensed . onzed Representative <br />,Y 1 Y(),) kli , hereby a tho4z\e 0 • / <br />1. 71, gent <br />to sign this San Joaquin Coun ell & Boring Permi AppliCation on my behalf. I understand this , <br />authorization is valid for one ye and is limitad)o the wo pla dated on the front page of this application. <br />---, <br />EHD 29-01 6-23-2015 <br />Site Mitigation Well Permit Application