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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 210 S. Stockton Ave. Ripon, CA <br /> PERMIT WP #:� <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby that I am licensed g with <br /> 7000) Of <br /> ion <br /> Division 3affirm <br /> of the California Business Professionseand e Code and m provisions of Chapter 9 y licensers sl in full forcet <br /> sand effect. <br /> Contractor Name: Cascade Drilling Technical Services Expiration Date: 9/30/2021 <br /> License#: 1058336 <br /> Title: Operations Manager <br /> Signature: r <br /> Print Na rY <br /> an Cook Date: 1/14/2020 <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 /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> X compensation insurance carrier and policy numbers are: 11/1/2020 <br /> Carrier:ACE American Insurance CompanyPolicy#: WLRC65890252 Exp. Date: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any pehat if I <br /> rson in <br /> any manner so as to <br /> should become subject compensation <br /> to wo kers' compensat on provisi ns of Section 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: Bryan Cook <br /> COVERAG <br /> UL, AND SHALL <br /> WARNING: ITANSEMPLOYER TO CRIMINALSNSATION E ALT ES AND CIVIL FINES IS UPTO $oo,000, IN <br /> SUBJECT <br /> INTEREST ATTORNEYS FEES, AND DAMAGES <br /> ADDITION TO THE COST OF COMPENSATION, <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> , hereby authorize Chey enneeWaalldm a 9 <br /> Bryan Cook Mt <br /> Nam Co Licensed Authorized Repnsentawe <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 /> r !� <br /> NGSr Ilcensed AUMedzed Repnsentaslve <br /> Site Mitigation Well/Boring Permit Application <br /> EHD 29-01 8-1-2017 <br />