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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: ?� OS .S. Mum 4�.� ov DriV �A PERMIT WP #: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. Contractor Name: TE Cr - License M 70 6 56 91 Expiration Date: OS/31 f.2 D.21 Signature: Title: R1;1 D Print Name: M ar IL J c-rrn 6a k Date: D/ /a a /21>?p WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self-insure for workers' compensation, as 13 provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the }� Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: &'r f-)c�qra Policy#: 72 wF-Ly9971 Exp. Date: o D a I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, and agree that if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Signature: Print Name: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION I, /"a� J�rp k cf k -, hereby authorize o c c _Su r r P rl C�/ ...Ill enema 11\ .iz RePrtsanla,na p . of !Lo R9en1 to sign this San Joaquin County Well& Boring Permit Application on my behalf.I understand this authorization is valid for one year and 1 .limited to the work plan dated on the front page of this application. e o1`Ul nlW Pulhanze ReprtxnWiva EHD 29-01 1t-1-2017 Site Mitigation Well/Boring Permit Application