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Signature: <br />Print Name: avx 14 1) ey5 <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: t <br /> <br />PERMIT WP #: <br /> <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: OIC/t <br />License #: 1 P0 @tMI C <br /> <br />Expiration Date: S1' /31 / 7 <br /> <br />Signature: ‘114. <br /> <br />Title: Pf e5;-11 elvr <br /> <br />Print Name: <br /> <br />140 H r4 y <br /> <br />Date: 4 • 1- 21 <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: <br /> <br />Policy #: 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 />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, ATTORNEYS 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 />I, R i mo 14 n m ay 5 , hereby authorize KI' r r La,w.18 It)/ A) A-1-5 <br />Name of 0-57 Licensed Authorized Reptresentati Print Name of Authowized 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,Jtnited to the work plan dated on the front page of this application. <br />tigiYattlfrtiaC-5 idcensed Authorized Representative <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application