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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT WP IV <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby aRnn that I am licensed Soler the provisions of Chapter 9 (commericing with Section ]000) of <br /> Division 3 mthe California Funguses and Professions Code and my license is in full force and effect. <br /> Contractor Name. =oNuarem^.d se^re+ <br /> License If asum Expiration Lane: severe <br /> Signature. OAa79 _rifle: V.P. Operations r <br /> Print Name: Ralph McGahey Data 621I2019 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the Sharing decimations: (check one) <br /> I have and wtu maintain a mu fiate of consent to self-insure for workers' compensation, as <br /> 0 provided for by Sector 3700 of the Labor Code, for the performance of the work for which this <br /> Brit is issued. <br /> I have and volt maintain cookers' compensation insumnce, as required by Section 3700 of the <br /> ® labor Code for Me performance of the work for which this permit is means, My workers' <br /> compensation insurance Gamer and policy numbers are: <br /> Carrier: Ace American Insurance Co. Pollcy N: 1ALNCBM34929 EYp. Date: 11A)WO19 <br /> 1 certify Mal in the performance of the weak for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject the workers' compensation law of California, and agree that if I <br /> should become subject to workers compensation provisions of Section 37M1 mthe Labor Cade, I shall <br /> forlhwtM comply with those provisons. <br /> Signature. <br /> Prim Name Ralph MCGahey <br /> WARNING: S SECURE COMPENSATION RC UNLAWFUL,SUBJECT AN EMPLOYER CRIMINAL PENALTIES AND P CIVIL FINES TO g10(i IN <br /> ADDITION TO THE COST OF COMPENSATION, WTERi ATTORNEY 8 FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF WE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN CST SIGNING PERMIT APPLICATION <br /> Friar MoGahhey_ hereby authorize Seasick Achi <br /> to sign this San Coumb & Baring Permit APPlicatb <br /> authorization Is valid far Well neyear and is limmad ro the work plan dated on the !front of this application. <br />