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JOB ADDRESS <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />3028 Navy Drive, Stockton, Ca 95203 <br />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: Middle rth Geo Ttzqtinn Inc. <br />License #: 451Expiration Date: �D % <br />Signature: Title: <br />Print Name: 1,11x nCOG Date: Z L2_ 2- lit <br />WORKER '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 />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: 5J -4-c COrr p• 1"ow, VktxA Policy #: �051 Z23 -2-011 Exp. <br />1 Exp. Date: L /$ <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 subj t to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />fo with comply with those provisions. <br />Signature: <br />Print Name: fpG <br />WARNING: FAILURE TO SECURE W K S' COMP------ O COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER 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 />1, Arn ay l ArA, V. J:• ncoc(,,� hereby authorize4zW& L2T <br />Name of -57 Licensed AuthonzeC Rliprsentative NIM 11.ff. of Authorized Agent <br />to sign this San Joaquin County Well & oring Permit Application on my behalf. I understan this <br />authorization is valid for one year and is limit tae work plan dated on the front page of this application. <br />EHD 29-01 8-1-2017 1 <br />Site Mitigation Well/Boring Permit Application <br />