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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS : 1200 Humphreys Street , Stockton CA 95203 PERMIT WP # : <br /> LTJ <br /> LICENSED CONTRACTORS DECLARATION <br /> 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 : Penecore Drilling , Inc <br /> License # : 906899 Expiration Date : 11 /30/2023 <br /> Signature : �C'a6xe, ,� 6JAzaov Title : Project Manager <br /> Print Name : Xa \/ IPr C� CPAn Date : 6/ 16/2022 <br /> WORKERS ' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations : ( check one) <br /> 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 /> 1 have and will maintain workers ' compensation insurance , as required by Section 3700 of the <br /> `r 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 : SCIF Policy # : 9281163 - 2022 Exp . Date : 8 / 1 /2022 <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 <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 : q"00 <br /> Print Name : Xavier Green <br /> WARNING : FAILURE TO SECURE WORKERS ' COMPENSATION COVERAGE IS UNLAWFUL , AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $ 10090009 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 , Xavier Green , hereby authorize Kimberly Brandt <br /> Name of C-57 Licensed Authorized Representative Print Name of Authorized 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 /> Signature of C-57 Vonsed Authorized Representative <br /> EHD 29- 01 04-07-2022 Site Mitigation Well/ Boring Permit Application <br />