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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: }� �'j Qtl�v H��? 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 #: y <br />-1- Li! )Xi �1IExpiration Date: <br />Signature: Title: Vi -e kL/ <br />Print Name: (; <br />Z z <br />D.1te: S), <br />J <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-inisure for workers' compensation, as <br />0 provided for by Section 3700 of the Labor Code, for the Qcrformance 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 />13 Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are:j <br />Carrier: _ �'aYlt� _ Policy #: `� l `�, � ? (� Exp. Date: 10/Z/L1 <br />I certify that in the performance of the work for which this per it is slued, I shall not employ any person in <br />any manner so as to become subject t9 -Workers' comp nsation law of California, and agree that if I <br />should become subject to workers' corhpensation provisioO of Section 3700 of the Labor Code, I shall <br />1 i fo�rtrhw h comply with those provisions. <br />Signature: <br />Print Name:^a;''tI <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 <br />`-Cv!.\ 'Q— 5} <br />to sign this San Joaquin County <br />authorization is valid for one dear ant <br />IER THAN C-57 SIGNING PERMIT APPLICATION <br />GG <br />hereby authorize elft -kG�l 4 '�b�utiGi�F} <br />I & B ing Permit Application n my behalf. I understand this <br />imited thwork plan date on the front page of this application. <br />EHD 29-01 8-1-2017 1 Site M hgation'NelYBoring Permit Application <br />