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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 3081 North Tracy Boulevard, Tracy CA 95376 PERMIT SR#: <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 Drilling Services > <br /> License#: 1012248 Expiration Date: Q✓?/3�/ZC�2�2 <br /> Signature: ; Title: <br /> Print Name: Dennis Ott Date: L Zd <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 /> 13 provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> i 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:,S�pj-e -CA/rYl Policy#: O'^CQ mW/—I Exp. Date: <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 t workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> f ithwith comply with those provisions. <br /> Signature: <br /> Print Name: 2) ,fj4,,g OTT <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 /> \C Nxb6Ehereby authorize Daniel Monteverde <br /> —�Irna ei f.�> enaed Authdly ReLnsentallyI PAnl Remear Aulhahe Aatnl <br /> to sign this San Joaquin County Well Boring PqAlt Application on my behalf. I understand this <br /> authorization is valid for one year and i i itadrtoork plan dated on the front page of this application. <br /> le <br /> Vpr1IW Repre6eiU.IM <br /> EHD 29-01 rr23-2015 Site Mitigation Well Permit Application <br />