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License #: 11 SI c,s- <br />Signature: (7- <br />Print Name: 64,7Z - <br /> <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS <br />0 4 C (t1J) 54-06w-fc, 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: 6ren DctIi 4Teeta, <br />Expiration Date: < //0 <br />Title: 0,efe? Ili-a/2r /Woo 0F..ae- <br />Date: <br />WORKERS' COMPENSATION 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 />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 <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: J C.7"- _.cloc -c? Policy #: Exp. 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 to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith com ly with those provisions. <br />Signature: <br />Print Name: CAP-:<,- <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 /> <br />,hereby authorize gc*, rs< c J uAr-tme_++ , Sc,,nolor or Morpy, ikafurc <br />Pnnl of Aulldulloci—Aryanl Narnv of ,:•trt 1.,cen•-ca PutOntuccl Itepro,entl,tve <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 lii e to I - ork p n atcd on the front page of this application. <br />41111Vor <br />ig nahne of 47 Uunod Atilheitted Reprevardal We <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application