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JOB ADDRESS: <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />Ia]: XNW=I:JA'%Ir7'� <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: I a W y <br />License #: 1 Expiration Dat : _�130 <br />Signature: -4_J <br />Title: Pocis (� <br />Print Name: Sf r '1 - Date: <br />lydlelzrX —Ri <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 />com ensa ion In nce carr er and policy numbers are: <br />f <br />Carrier: J t�i� 1 G1, % Policy#: I 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 orkers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisio s of Section 3700 of the Labor Code, 1 shall <br />forthwit complX with those p ovisions. <br />Signature:*� <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS"SOMPENSATION 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 />AU HOIRWATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize uht <br />Nnm of L.nnwl Autlgn»d .prt>N "_ un AutAo—d Agent <br />to sign this San Joaquin Coun Well & BorinPermit mit Application on my behalf. I understand this <br />authorization is valid for oney arand Xs�imited to he work plan dated on the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />