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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 140 So iirt\ Am\ P. jk PERMIT WP #: <br />'7-ra t,i I Cf1/9!` r <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 #: <br />1--1 Dp;11 <br />1170 67 <br /> <br />Expiration Date: ¶/) J2..1 <br /> <br />Signature: <br /> <br />Title: p r <br /> <br />Print Name: <br /> <br />)Z AA H utwifivtty <br /> <br />Date: - - <br /> <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 />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 />Carrier: Policy #: <br /> <br />Exp. Date: <br /> <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 />Signature: <br />Print Name: <br /> <br />R tr‘ 14 IA op\ re y s <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 />)--Itivnp1NceN4 5 <br />Name of C-57 Lice <br />, <br />ed Authonzdd iepresentative <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" limited to the work plan dated on the front page of this application. <br />gna of C-57/./Ice Auiliorized Representative <br /> <br />, hereby authorize <br /> <br />14/ 'fr'T Aynk A-V5 <br />Print Name of Authorized Agent <br /> <br />Site Mitigation Well/Boring Permit Application EHD 29-01 8-1-2017