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San Joaquin County Environmental Health Department <br /> WELL &BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 12030 Harlan Rd _ _ PERMIT WP#: <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: Yellow Jacket Drilling <br /> License#: C67-1034407 Expiration Date. <br /> Signatt!re: -29--1 ,, Title: District Mnager <br /> Print Name: Dean Coblish Date: 7/12/2019 <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 3700 of the <br /> El 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: Travelers Indemnity Co Policy#: UB-2J440716-19-26 Exp. Date: 4/1/2020 <br /> 1 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: r/ <br /> Print Name: Dean Cobish <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRiM1,NAL PENALTIES AND CML 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 /> 1, Dean Coblish ,hereby authorize Rachel Kerr <br /> ."".a <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 /> � d <br /> EHD 29-01&1-2017 Site Mitigation WeIUBodng Permit Appkatton <br />