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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 135 Miner St. Stockton, CA 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:" 1� � �y 1 6?0 - `Z - � <br /> License #: c Expiration Date: be 3 D Z <br /> Signature: Title: /Jv <br /> Print Name: 2eo Date: l 20 12 092 <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 /> O 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 /> 0 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 /> Carrier3.46t 2 0,QMV S` 'tL dPolicy#:9a5'�073 _20,Z Exp. Date: 2 42 <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 /> f hwith comply with those provisions. <br /> Signature: <br /> Print Name: ✓��%� C �Le <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 /> AUTHO/jRIZA�TIION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize <br /> Name of C-57 Mensed Authorized RepreceMative Print Name of Authorised Agent <br /> to sign this San Joaquin County Well & Boring Permit Application on my behalf. 1 understand this <br /> authorization is valid for one year and is lim' the work plan dated on the front page of this application. <br /> _TWato of 457 Licensed Authorised Repr ve <br /> EHD 29-01 04-07-2022 Site Mitigation WeIVBoring Permit Application <br />