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San Joaquin County Environtnental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> #: D <br /> 1200 Humpfreys(See Work Plan)_ <br /> PERMIT WP � <br /> JOB ADDRESS: — <br /> LICENSED CONTRACTORS DECLARATION <br /> m licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> I hereby affirm that I a license is in full force and effect. <br /> Division 3 of the California Business and Professions Code and my <br /> Name: <br /> Contractor Expiration Date: <br /> License#: <br /> Title: <br /> Signature: �L� Date 5 <br /> _ '. <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> declarations: (check one) <br /> t to self-insure for <br /> I hereby affirm under penalty of perjury one of the following ensation, as <br /> I have and will maintain a certifica e ofconsen Labor Code, fo tithe performanc e of the work for which this <br /> ❑ provided for by Section 3700 of the <br /> permit is issued. Section 3700 of the <br /> of the work for which this permit is issued. My workers' <br /> I have and will maintain workers ecompensation insurance, as require y <br /> ❑/ Labor Code, for the performance ( � <br /> compensation insurance carrier and policy numbers Q 1 r Exp. Date: <br /> I 0CG A �t�Policy #: <br /> Carrier: �C �CU ���`1 t � to an person in <br /> permit is issued, I shall not employ agree y p rs if I <br /> I certify that in the performance of the work for which this p ensation law of California, and <br /> any manner so as to become subject to the workers' comp <br /> to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> should become subject' forthwith comply with those provisions. <br /> Sig nature: <br /> Print Name: f", <br /> AND SHALL <br /> CRIMINAL PENALTIES AND CIVIL FINES EE gNp1DAMAGES <br /> WARNING: F' ILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, <br /> SUBJECT AN EMPLOYER TO <br /> ADDITION TO THE COST OF CTION 3706 OF THE LABOR CODEPENSATION, INTEREST, ATTORNEY <br /> AS PROVIDED FOR IN SE <br /> AUTHOR IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> J ` , hereby authorize pdnt Name of Authorized Agent <br /> behalf.I understand this <br /> Nema of GST Llcensedt the dRepresentatfvc Permit Application on my lication. <br /> year and is IimitWo the work plan dated on the front page of this app <br /> to sign this San Joaquin County Well &Boring <br /> authorization is valid for one y <br /> nature of GST Llceosed 0.uthorlled R<prceenlel Pte <br /> Site Mitigation Well/Boring Permit Application <br /> EHD 29.01 8-1-2017 <br />