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SaN OAHIN <br />a COUNTY— <br />G, co ! n r s s <br />OUNTY—G,co#nrss mows :,err. <br />• <br />Environmental Health Department <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 17720EHarneyLane. Lod CA 95240 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 />Casade Driul <br />License #: 93wo Expiration Date: 09!90/2017 <br />Signature: �'' Title: <br />Redlonal Director <br />Print Name: Re,eh WC-ahev Date: 08715I2o17 <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 />13 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 />ACE American Insurance <br />Carrier: Company Policy #: WLRC49106075 Exp. Date: 11/01/2017 <br />1 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 />00..� - . forthwith comply with those provisions. <br />Signature: '" <br />Print Name: Ralvh McGahey <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 />I Ralph McGahey , hereby authorize Alberto Vasquez <br />r <br />Nam or Cd7 titomad A thortaod Rept".Mativa Print Nam. Au horizod Aaant <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />EHD 29-01 C"1-17 Site hliliaation Weit Pem* A0011caeon <br />