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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 30707 Corral Hollow Rd.,Tracy, CA 95377 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 <br /> and Professions Code and my license is in full force and effect. <br /> Contractor Name: me &6 <br /> License#: 011e1 Expiratiopn Datel: II' 36- dGZ� <br /> Signature: \/ am/ Title: id C1 wrI // <br /> Print Name: &V'%Pit" bf te'(1 Date: -`�- 20 <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 /> 17 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 /> W <br /> Carrier: C51Cb ]�ylw4kge'e Policy#: Py(-�L\677G Exp. Date: I gq� <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 sue <br /> workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: )(C1VIe( lilcn <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize (OwVNPi e$�f7�y)If t a 1 C Z <br /> xmmmanu mn.,m fl.Pre...un.. wpm x.re.m�m„rx.e y.m <br /> to sign this San Joaquin County We I &Boring Permit Application on my behalf.I understand this <br /> authorization is valid for one year d limited to the work plan dated on the front page of this application. <br /> �6/ 819naNreWGSI LxmsM�VtlwIM flePrtsenhxre <br /> EHD 29-01 8-1-2017 t/// Site Mitigallon WeIVBoring Permit Applica0on <br />