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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 622 E. Lindsay Street and 601 E. Miner Avenue <br />PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />1 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: Geocon Consultants Inc. <br />License #: 7,soso y <br />Signature: <br />Pant Name: Bob Kimball <br />Expiration Date: 12'31'23 <br />Title. Construction Manager <br />Date: <br />RS' COMPENSATION DECLA <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 />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 />® 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" Transport <br />ation Insurance Co. <br />Policy #: WC679910107 <br />Exp. Date: 1/1/2023 <br />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 1 <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: z <br />% - <br />Print Name: Bob Kimball <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1S 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 />11011 <br />/30/? J 4 i% ,hereby authorize <br />Name or CS7 Licensed Authorized <br />Representative <br />to sign this San Joaquin County Well &Boring Permit Application on my behalf. 1 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 29-01 8-1-2017 Site Mitigation WelUBol7ng Permit Application <br />