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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOBADDRESS: S ,)VV �, r����� �;�Q 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: Cascade Drilling,L.P. <br /> License#: .1058336 Expiration Date: 9/30/2021 <br /> Signature: dMZ Title: Project Manager <br /> Print Name5iyan Cook Date: 12/16/2019 <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 /> 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 /> 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 Co. Policy#: WLRC65890252 Exp. Date: 11/01/2020 <br /> i <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: <br /> Print Name: 1 n Cook <br /> v � <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, Bryan Cook hereby authorize q,)tA>v SAu�!,_�C-ZAV <br /> o oTc?svnm Na ,e,naTn.aeny.m <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 /> EHD 29-01 8-1-2017 Site Mitigation WelilBoring Permit Application <br />