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RECEIVED 0 9 <br /> San Joaquin County Environmental Health Department <br /> APR 05 2016 WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ENVIRONMENTAL <br /> HEAJADDMMSST � <br /> � W,OB ` ] e y 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 alifornia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: . <br /> License #: Expira ' nDate: <br /> Signature: / Title: V� <br /> Print Name: V G1, Date3HIP <br /> WORKERS' C0,1_MRATInm 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 /> JLC\ 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#:li_�02_d 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 wo er ' compensation law of California, and agree that if I <br /> should become subject to worke/s`compensate n pr visions of Section 3700 of the Labor Code, I shall <br /> o with co m/7 <br /> those provisions. <br /> Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORK RS' OMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO FIMINAI 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 SEC�TI N 3706 OF THE LABOR CODE <br /> AUTHO AT N FOR /OTIIER THAN C-57 SIGNING PERMIT APPLICATION <br /> t <br /> I, hereby authorize j <br /> Uzi <br /> to sign this San Jo m•County II & ipg Permit Application on my behalf. I understand this <br /> authorization is valid for one e r and i Ii t r he work pl dna�d on the front page of this application. <br /> sea.• 0 . :.a RlT.. <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />