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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> . k AMJOB ADDRESS: V� 1 l PERMIT SR #: <br /> u4N IOD Its" <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 California1 ( <br /> usiness and Professions <br /> Code and my license is in full force and effect. <br /> Contractor Name: A �Jr `\ <br /> License #: ( Expiration Date: <br /> Si nature: \ <br /> g �. Title:Sf <br /> Print Name: Date: <br /> WORKERS' 1PENSATION 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 /> Cly(\ Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> comQensatJon inrnce carr.er and policy numbers are: <br /> Policy#: —Carrier: f <br /> Exp. Date: 1 �5 <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 orkers' compensation law of California, and agree that if I <br /> should become subject to workers' corlpensation pro visio s of Section 3700 of the Labor Code, I shall <br /> forthwit comply with th, e p ovisions. <br /> Signature: 4 <br /> Print Name: d L <br /> WARNING: FAILURE TO SECURE WORKERS' MPENSATION 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 /> A/UHO ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, �( LA,_ , hereby authorize <br /> Name of C d7 L.cene d Autnonad Regr*MfftMiw Pnm NMr of A.I n.Agent <br /> to sign this San Joaquin Coun Well & Boring Permit Application on my behalf. 1 understand this <br /> authorization is valid for one yf ar and is invited to'the work plan dated on the front page of this application. <br /> 4�J,)' , I <br /> ! 1,\4()&I u"\'o <br /> Signa[um M C477uthaabAqn <br /> rl <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />