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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 29`I5 Vj. VAARj4.E LAnJE PERMIT SR #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) o` <br />Division 3 of the (jalifopiqZusiness and Professions Code and my license is in full force and effect. <br />Contractor Name: VVj- A n �1 1 V l/ . <br />NO <br />Sinnature: Title: <br />Print Name:.�C!! �. _ <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 />Labor Code, for the performance of the work for which this permit is issued. My workers' <br />en ation ' urance c rrier and policy numbers <br />are: <br />Carrier: Policy #: Exp. Date: <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 becomes ect to the rs' compensation law of California, and agree that if I <br />should becomes ject to w rker ' compen do provisions of Section 3700 of the Labor Code, I shall <br />1 f rthwith ccnply ith those provisions. <br />7 &\ <br />Signature: (J <br />---- — <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' C NSATION 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 />UTHORIZATION FOR OTHER THAN C-57 SIGNI <br />�TQ7�__—-herelYyauth rize__ 'srnl -W Rrprex a;rve-.___.._ __ <br />to sign this San Joaquin County el Boring P rmit plic <br />authorization is valid for o�ne,y ar�?nd i lim ted to the o Ian <br />Vf 1 ii Y, n I/\%> n ,vzt i <br />MIT APPLICATION <br />I/ <br />my behalf. I under Land this <br />the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />