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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 215`t S 0 Dor,-mk> SL-,S)ru1<-k41(-<t `)52.04 PERMIT WP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I 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: CAsC�t t.�-) Or I1 i n�� <br /> License#: I u S93 36 Expiration Date: 0 rl/3 o/2 <br /> Signature: /evff ry Title: Project Manager <br /> Print Name: Matthew Tolbert Date: 3/13/2025 <br /> WORKERS' COMPENSATION DECLARATION <br /> 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: ACE AMERICAN INSURANCE COMPANY Policy M WLR C68933663 Exp. Date: 11/1/2025 <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 /> ffo-rtthhwith comply with those provisions. <br /> Signature: `` <br /> Print Name: Matthew Tolbert <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, 1N <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� Matthew Tolbert ,hereby authorize Willem Scherwin <br /> Nome of C 67 U—Sod Authorized Rep—hietive Print Nema of Authodzad Agent <br /> to sign this San Joaquin County Well&Boring Permit Application an 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 /> Bpnetun of C47 Lkans Authorzed R.preeanGWo <br /> EHD 29-01 04-20-2023 Site Mitigation Well/Boring Permit Application <br />