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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: ic,k ' �� ` PERMIT SR #: <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 <br />License #: <br />Signature: <br />Print Name <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 />)xc Labor Code, for the performance of the work for which this permit is issued. My workers' <br />pens7 A tion i ranee ca rier and policy numbers are: <br />Carrier: Policy #:y1l ) J C�4p- )�> Exp. Date: <br />C c <br />I certify that Je performance of the work for w s permit is issued, I shall not employ any person in <br />any manner so as to become subject to thew rkers' c mpensation law of California, and agree that if I <br />should become subject to workers' compens ion pro4isions of Secti 3700 of the Labor Code, I shall <br />rthwith corn ly with those provisions. <br />Signature: -J V <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPXASATION 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 />Qe; <br />hereby <br />to sign this San Joaquin County Well eBoring Pi <br />authorization is valid for one year ri is li i rd to the <br />11 11 ) , 1 NFA . <br />SIGNING PERMIT APPLICATION <br />ttyorize 1 <br />w�fr_� <br />Pn t Nime t Authonzed Aq nt <br />Application do behalf. I understand this <br />;,plan dated' on <br />a front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />