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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 'l, PERMIT SR #: <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 Cialifornia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: <br /> License #: 1W Expirat on Date: L` <br /> Signature: ► N-6Title: <br /> Print Name: Date: <br /> WORKERS' COMPEN6TION 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 /> CI provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 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 /> c pens tion i urance ca rier and policy numbers are: Or9ill <br /> Carrier: oiic #: Exp. Date: <br /> I certify that in the performance of the work r whic this pe s issued, I shall not employ any person in <br /> any manner so as to become subject to th work s' co pensa ion law of California, and agree that if I <br /> should becomWsubj Ztowo ers' compen atio provisions of ection 3700 of the Labor Code, I shall <br /> forthwith co pl wit hose p visions. <br /> Signature: <br /> Print Name: 51LL <br /> WARNING: FAILURE TO SECURE WORKERS' CO PENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIM L 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 /> hereby aut rizeJon <br /> Z <br /> a of C37 Licensed Authorized epresentative of A died Ag t �� f�S frto sign this San Joaquin Coun W 11 & orin Permit A plicehalf. I understand this ('/,wn(/l�authorization is valid for one ye a d is a to he work pan dont page of this application. <br /> Signatune of C•67 Licensetl Autnorize eD s ative V \\J <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />