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JOB ADDRESS: 6701 Jac PERIIIIT SR #: <br />LICEISED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under t le provisions of Chapter 9 (commencilig with Section 7000) of <br />Division 3 of the Califomi Business and Professions Code and my license is in full force and effect. <br />Tone Road Stockton, CA 95215 <br />Contractor Name: MIDDLE RTH GEO TESTING INC <br />License #: 899451 Expiration Date: 6/30/2021 <br />Signature: <br />Print Name: <br />Title: <br />co-40 Date: <br />tN I/n, Aine410 <br />AUTHORIZATION FOR OT <br />(00 <br />Sign. <br />Site Mitigation <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />I have and will m9 ntain a certifi ate of consent to self-insure for workors' compensation, as <br />provided for by S lotion 3700 of he Labor Code, for the performance of the work for which this <br />permit is issued. <br />I have and will mantain workers compensation insurance, as required by Section 3700 of the <br />Labor Code, for tH performanc of the work for which this permit is issued. My workers' <br />compensation ins rance carrier nd policy numbers are: <br />Carrier: u‘ k_ ( <br /> <br />111 Policy #: xp. Date: WZA/ <br />I certify that in the performarI ce of the wor for which this permit is issued, I shall not employ any person in <br />any manner so as to becorpe subject to t e workers' compensation law of California, and agree that if I <br />should become subject rkers corn nsation provisions of Section 3700 o' the Labor Code, I shall <br />fo ith co ly with those provisions. <br />Signature: <br />Print Name: <br /> <br />WARNING: FAILURE TO sECURE WORKE • MPENSATION COVERAGE IS iJNLAWFUL, AND SHALL <br />SUBJECT AN Ili LOYER TO RIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF C MPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 706 OF THE LABOR CODE <br />it E THAN C-57 SIGNING PERMIT PPLICATION <br />, hereby authorize <br />Print Name of rhorlred Ag•nt <br />to sl this San Joaquin p unty Well Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and is Ii ted to the work plan dated on the fronti page of this application. <br />EHD 29-01 6-23-2015 Well Permit Application