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RECEIVED 0 <br /> FPR U 5 2016 San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> JOB ADDRESS: Z S W , C t� fW%X PERMIT SR#: <br /> SfiaG�1�a✓l � <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 tAalforniausinessand Professions Code and my license is in full force and effect. <br /> Contractor Name: t t , <br /> License #: Expiran Date: <br /> Signature: Title: <br /> Print Name: VAZ 1 V1 Date: <br /> 3 <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 /> 0 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 /> JCS\ Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> c pensatio surance carrier and policy numbers are: <br /> Carrier: Policy#: 1 O Exp. Date: <br /> I certify that in the performance of the work for w c this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the woer ' compensation law of California, and agree that if I <br /> should become subject to worke�Compensati n pr visions of Section 3700 of the Labor Code, I shall <br /> o with comp) wi those provisions. <br /> Signature: % V <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WOR RS' OMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO IMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST q COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SE71 N 3706 OF THE LABOR CODE <br /> Trf <br /> N FOR / T ER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, hereby authorize 61 <br /> n.• mn em.w artn.n:.a aa..t <br /> to sign this San Jo 1ne ounty If & i g Permit Application on my behalf. 1 understand this <br /> authorization is valid for one e r and i If it p the work pl da d on the front page of this application. <br /> Signa <br /> 129-01 6-23-2015 Site Mitigation Well Permit Application <br />