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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT/APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 363"i w Stewart Rd(5outh of Cci 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 California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: California Push Technologies, Inc. <br /> License #: 884827 Expiration Date:__-, - <br /> >, <br /> Signature: <br /> Print Name: v i,rr` <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 /> 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. POliC #: f , <br /> ' � � jz �c,n �,.,..,w. v,1,.� y �( `� Exp. Date: ---IT 2G 17- <br /> 1 <br /> 1 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 TO SECURE WORKERS' COMPENSATION! 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. ~�4- `vX f'� �- ,'t_ hereby authorize "hr.istophe.r Stourfe: <br /> Hame d C-s7llun.ee AirtMrizeC R r c®r iz!.r - - - - —_ hint Na of AuMwixad AgW"t <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 /> &JdAuroy - aCru0JzW R.p_wtfw <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />