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) • r <br /> San Joaquin County Environmental Health Department <br /> AUG 2 5 2016 WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> b661--ABBESS: V1�`�z Rei i 12�:��> V;, "p,CR PERMIT SR #: <br /> 87330 <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commenci ig 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: 4/30/17 <br /> Signature: 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: (check 3ne) <br /> I have and will maintain a certificate of consent to self-insure for womt rscompensation, 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 /> C3 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 Exp. Date: 2/1/2017 <br /> I 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 c f the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: ld,- V-,� <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 PERMIT APPLICATION <br /> I, hereby authorize <br /> Nacre MC V 1-1—mal AutM1eXaeE Nepamrgrlw Pdnt Nam a AdlaeiZM Agent <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 fror t page of this application. <br /> slanatum a C-n IJwneN AmNanzN HeprteemMive <br /> EHD 29-01 6-23-2015 Site Mitigati n Well Permit Application <br />