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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: LQ Y) PERMIT SR #: <br />,-CYC t <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: V A O N&I, <br />License #: '� wExpiration Date: <br />Signature: Title: <br />Print Name: 1 ( ( Date: <br />WORKERS' C ENSATION 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 />j� I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />E� Labor Code, for the performance of the work for which this permit is issued. My workers' <br />con3pensation ioeorance carrier and policy numbers are: ttt�1 <br />Carrier: Policy #: — 1 '7 Exp. Date: Kl C <br />I certify that in the performance of the work for which this permit is issued, <br />_I_shall not employ any person in <br />any manner so as to become subject to thewrk rs' compensation law of California, and agree that if I <br />should become subject to workers' compens tion provisions of tion 3700 of the Labor Code, I shall <br />/ _ ;'-forthwith comply with those tu'bvisidns. <br />Print Name: Va VI', <br />WARNING: FAILURE TO SECURE WORKERS' ,,POPENSATION 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 />!u I N LA VN 1 -UK U I HER THAN C-57 SIGNING PERMIT APPLICATION <br />here auth rize <br />um m uthorimINnLt ve i uth <br />i <br />to sign this San Joaquin Coun ell & Boring Pe mit A' plicati n on y behalf. nderstand this <br />authorization is valid for on year n is lird�6t d to the rk Ian da d on I ie front page of this application. <br />W I i, <br />s <br />EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />