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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 9500 West Linne Road, Tracy, CA 95377 PERMIT WP M vv <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:EnProbe Environmental Direct Push Drilling Services (EnProbe) <br /> License#: 1012248 Expiration Date: 03/31/2024 <br /> Signature: Title: CEO/Owner <br /> Print Name: Dennis Ott Date: August 23rd, 2023 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> 0 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 /> M 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: State Farm Insurance agent Policy#: 90-GB-W349-6 Exp. Date: 03/15/2024 <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 /> S / Q/ forthwith comply with those provisions. <br /> Signature: <br /> 111- <br /> Print Name: Michel Helou <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, Dennis Ott , hereby authorize Michel Helou <br /> ameor 047 Ll-...d A.MMI.dRe1—U a Pont We of m a x Agent <br /> to sign this San Joaquin Cou ty Well&Boring Permit Application on my behalf.I understand this <br /> authorization is valid for one year z d is limited o the work plan dated on the front page of this application. <br /> ' sgn4n Lkene.e AmnoraeG R<Pe:emnwe <br /> EHD 29-01 04-20-2023 Site Mitigation Wer/Boring Permit Application <br />