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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> (��I —7q— <br /> JOB ADDRESS: 1810 E. Hazelton Avenue, Stockton, CA 95205 PERMIT WP #: t I <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: Environmental Control Associated, Inc. <br /> License#: <br /> C57-695970 Expiration Date: 09/20/2024 <br /> —�_ „ Title: President <br /> Signature:��� <br /> Print Name: Timothy B. Tyler Date: 12/19/22 <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 /> 13 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 /> 10 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: <br /> STATE COMP. INS. FUND policy#: 1972096-22 Exp. Date: 05/01 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any per�,vr f r r <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: 7.� PiOR- <br /> Print Name: Timothy B. Tyler <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 /> 1, Timothy Tyler hereby authorize John Lane, Condor Earth <br /> Pdn,Name of AuNodzW Rgen, <br /> Name W C5]lkenseE Au�oAzed RepresenUlive <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one vear and is limited to the work plan dated on the front page of this application. <br /> ' ^ i.0 Mftori etl Represmtaeve <br /> EHD 29-01 04-07-2022 Site Mitigation Well/Boring Permit Application <br />