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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: JrZtN,c ;V_L) f3fc�- iX:e641 U urlr-n PERMIT WP M �� <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: L,ff-0 —I am(, J WCLAJ S Inc <br /> License#: (15/-4 Z Expiration Date: 12� 31 12C2 3 <br /> SIgnaIu re: <br /> �p/�w� !/,f' �/ Title;R�IE f} �i�rora✓lw di.,4 /{y� c-t7 <br /> Print Name:�,��f!/fin S J/y .'m G•�/ Date: 7- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 13 1 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:TYcto-%N-4z0uwi A"Policy M u-C 4 -4491 0I0 + Exp.Date: i i I Zc•2' <br /> I 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: �.� �3?, �'✓_,Y�f' <br /> Print Name: Ai 6er74 IfY. ,lam,- L// <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, 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 /> I-------- hereby authorize <br /> map csnnras uum«ali.p««^ . Mt an,ureuu,.rvm Nsn, <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 /> 38nalo«pr G31 «mM u1 pRMRepmnnplXa <br /> EHD 29.01 04-20-2023 Site PAitigalion Weli/Boring Permit Application <br />