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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION <br /> JOB ADDRESS: 530 North Stanislaus Street, 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: e"_, /0 r—o i <br /> License #: Expiration Date: t3l 0 <br /> Signature: Title: <br /> Print Name: P Date: Ct <br /> COMPENSATION <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: lic : FZLJeC-L-Y'11�13Exp. ate: <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 /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: <br /> WARNING: FAILURE SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINES UP TO $10070009 I <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEYvS FEES, AND DAMAGES <br /> ASPROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATIONTHER THAN C-57 SIGNINGIAPPLICATION <br /> 1' , hereby authorize Luke Castle (Condor Earth) <br /> Name of C-57 licensed Authorized Representative Print Name of Authorized Agent <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 /> Signatu a of 7 ice sed uthorized Representative <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />