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1. AHV 1 <br /> <br />L00 .d Aathantsrd kart 'WAR. r • <br />to sign this San Joaquin County Well & B <br />authorization is valid for one year and is li <br />, hereby authorize <br />plication on my behalf. I understand this <br />dated on the front page of this application. <br />Ban Joaquin County Environrolontol tiooltli DOp4rirnent <br />WELL & BORING PERMIT APPLICATION SUPPLIMENTAL <br />JOB ADDRESS: / 2 / S . CA- c i-0 Kc /4 4)4 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 <br />License #: 1 -2-q <br />Signature: Title. 06L-Wef/ <br />Print Name. iftiOS Of \A Date: Tie <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />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 car-- Labor Code. for the performance of the work for which this permit is is5ued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: Policy #. — (--,; gxp. 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 tp workers' ompensation provisions of Section 3700 of the Labor Code, I shall <br />with comply with those provisions. <br />Expiration Date: <br />Signature: <br />Print Name: A/4AI> 0/ <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 />kt4trilitw.04 C-S1 I MUNI 11,121.4)(1Z 4114Prilltwii, <br /> <br />EHD 29-01 fi-1-2017 <br /> Site Mitigation WelliSoring Permit Ariptication