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Well <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: .52/ za, /-41J PERMIT WP#: C' C"' 9 �l � <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: Cal-Nev Geo Exploration _ <br /> License#: 103918s Expiration Date: Os/3112 24 <br /> Signature: & � G TTitle: President <br /> Print Name: Alisha Tadlock _Date: 8/14/23 <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 /> ® 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: State Fund Insurance Policy#: 9289493-2022 Exp. Date: 12/21/2023 <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 /> �I'I� pwwr' forthwith comply with those provisions. <br /> Signature: - <br /> Print Name: Alisha Tadlock _ <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, ATTORNEYS 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 /> Alisha Tadlock , hereby authorize Steve Muir <br /> r+a.�o a r vcanwa rw+uonreo rep pemenvnc Pnm ereun.of lwkeman.+erne <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 /> 7ab& <br /> ` - :r.emn m cs uw.rc a„v.an.oa aranaw.cn.o <br /> EHD 29-01 04-20-2023 Site Mitigation Well/Boring Permit Application <br />