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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: is /) ?j Ct/i d;5 l i f (`tel l,C, I X11 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: 1, ,,F( �( I-1 �� ,� l `.I ; G, <br />License Expiration Date: (alp/a 3 <br />Signature: Title: '5ee <br />Print Name: o e,, �, Date: <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 -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 37001of 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: r,7,. rr�o=, rd.'s Prez;�.y�Policy#:SA, A�TwC�r��g��i Exp. Date: y,)j / It J <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 subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Print Name: ,��S,,4 <br />y <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 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, 1, hereby authorize <br />Name &C37 kensod Authorized Repreeentative print Nano o Authorized Agent <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand 1 <br />authorization is valid for one year and is limited to the work plan dated on the front page of this apr <br />glgnalun 0 C47 Licensed Authorized Representatlw <br />on. <br />EHD 29-01 04-07-2022 Site Mitigation WelUBoring Permit Application <br />