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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: C lvc RAVIL � PERMIT SR #: arc>c U'1- LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. Contractor Name: License #: �Expirat Date: Signature �, �, >V)') 24 Title: Print Name: y� j i \ Date: F - WORKERS' TION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as ❑ provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code. for the performance of the work for which this permit is issued. My workers' compensation i rance carper and policy numbers are: _ Carrier: ( �. �� ; Policy #: n� �' � �; Exp. Date: certify that in the performance of the work for which this permit is issue I shall not employ any person in any manner so as to become subject to thewor rs compensation la of California, and agree that if I should become subject to work s' compensat on provisions of Secti 3700 of the Labor Code. I shall f rthwith comp with those provis4dns. Signature: , I J Lin Print Name: V 61 � WARNING: FAILURE TO SECURE WORK ERS'_COJ IPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE UTH to sign this San Joaquin County/ authorization is valid for one year and )THER THAN C-57 SIGNING PERMIT ,APA?LICATION hereby autho ze �— Pim Name of Au nol-d Agen, Well & Bor g Permit Aplication on my beh f. I understand this is limit" o the work pIin ate,,d on the fro t page of this application. EHD 29-01 6-23-2015 Site Mitigation Well Permit Application