Laserfiche WebLink
San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1904 West Charter Way, Stockton, CA 95206 PERMIT WP #: 6 if <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: Confluence Environmental, Inc. <br />License #: 913194 <br />Expiration Date: 11/22/2023 <br />Signature: ,14c�a.% e: President <br />Print Name: Ralph McGahey 61 a Date: 08/15/2022 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury <br />one of the following declarations: (check one) <br />I have and will maintain a cert <br />ificate 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 />M 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: Van Oppen & Co. 2, Inc. <br />Policy #: 793-01-11-33-0001 <br />Exp. Date: 02/01/2023 <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: Ralph McGahey <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, Ralph McGahey ,hereby authorize Ronald M. Gestler of Geosyntec Consultants, Inc. <br />Named CdlLpnz AuNo Rep,aze ve P nt me olA rizeE Agent <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br />EHD 29-Ot 04-07-2022 Site Mitigation WelUBoring Permit Application <br />