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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 41 'G' 1 /-- 1 PERMIT SR #: <br /> j'11C1�,4Ccf�1 V!�-p , Cf-- <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 <br /> /'Code and my license is in full force and effect. <br /> Contractor Name: r) N%, �/+ l <br /> License #- t l 1 Expiration Dat [�b <br /> Signatur <br /> yl 1 _ \ -e: 4 �. Title: ��j -0 <br /> SifPrint Name: rc),I tA Date: <br /> WORKERS' MPENSATION 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 /> 13 provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> EX� ) 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 in nce carr er and policy numbers are: <br /> Carrier: JV <br /> .. Z� j Policy#: }— Q7Exp. Date: <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 to107"�workers' compensation law of California, and agree that if I <br /> should become subject to workers' compensation provisio sof Section 3700 of the Labor Code. I shall <br /> forthwit comply with thosep ovisions. <br /> Signature:` kfa.D YUf �I L <br /> Print Name. V" 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 /> r . <br /> AU HO ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 <br /> hereby authorize <br /> Num d v-0 l.canfeo Authonnd R.P—MM.Vrl int N�nr a!Autnoruea Apm <br /> to sign this San Joaquin Coun Well & Boring/ Permit Application on my behalf. I understand this <br /> authorization is valid for one y oar and is imited to the work plan dated on the front page of this application. <br /> YLI 1410 <br /> .prawn d C cmtue mn0 rrPr•un n <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />