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AUG 2 5 2016 San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> r <br /> JOB ADDRESS: ]Me"Nq� Q,J,�Q�JtQ. � Lamqja 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: Confluence Environmental, Inc. <br /> License#: 913194 Expiration Date: /30/17 <br /> Signature: I� �^ Title: President <br /> Print Name: Megan Kerns Date:$/23/16 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (checkOne) <br /> I have and will maintain a certificate of consent to self-insure for work 'rs' compensation, as <br /> 0 provided for by Section 3700 of the Labor Code, for the performance cf 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: State Comp Ins Fund Policy#: 1916919-2016 xp. Date: 2/1/2017 <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 Cali ornia, 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: Mega Kerns <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 PERMITAPPLICATION <br /> I, , hereby authorize _ <br /> eem of LS/LlceneM RNpo peprosenttlNe ptl^, e t �ABe^t <br /> to sign this San Joaquin County Well & Boring Permit Application on my beh If. 1 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 /> SlgnMum of Ln Llmnx AumoazW HepmuntMlw <br /> EHD 29-016-23-2015 Site Mitigati n Well Permit Application <br />