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San Joaquin County Environmental Healt Cepa ment <br /> WELL Hr BORING PERMIT APPLICATION 'AIPP EMENTAL <br /> JOB ADDRESS: 18551 Christopher Way (LAS-2) Lathrop, CA 95330 PE MIT SR#: 007374 / <br /> ' TION 007 S76P. <br /> LICENSED CONTRACTORS DECI ��F�. <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (c:)rrrr;mcing with Section 7000)of <br /> Division 3 of the California Business and Professions Code and my li( en:>e is in full force and effect. <br /> Contractor Name: 'iAi\ \\ rjrcet -- <br /> License#: _Expiration Date: ( e54 SOI-? C)1 k <br /> Signature: l _Title: . <br /> Print me: <br /> WORKERS' COMPENSATION DECLARA,rIDN <br /> I hereby affirm under penalty of perjury one of the following declarations ;cher one) <br /> 1 have and will maintain a certificate of consent to self-insure fel v,o ers' compensation, as <br /> provided for by Section 3700 of the Labor Code, fcr the perfc,rranrA of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, w: rt quir d by Section 3700 of the <br /> Labor Code,for the performance of the work for which this p(:=mit is ssued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Scams ,X,01 Policy#: 1crin 11— �_._ Exp. Date:IDEC <br /> I certify that in the performance of the work for which this permit is issue: 1, 1 sh II 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 370 of the Labor Code, I shall <br /> forthwith comply with those provision:: <br /> Signature_ <br /> Print Natrie: Z-)• ICLcYt _ <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVEF.4431: I 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, A.1TORN&S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION F R OTHER THAN C-57 SIGNING P ERMIIT APPLICATION <br /> I, hereby authorize <br /> ,.� a�.o....mm» <br /> t eWn this7an Joaquin County Well & Boring Permit Application o i my behalf. I understand this <br /> authorization Is valid for one year and is limited to the work plan dated of the front page of this application. <br /> 519notum q ♦ .p Wm - <br /> EHD 29-016-23-2015 l:ate Miligation Well Pe nit Application <br />