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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> �JOB ADDRESS: 0m, <br /> 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 ProfessionsCode and my license is in full force and effect. <br /> Contractor Name. t` <br /> License#: ( 1 1 Expiration Dat <br /> Signature: ��Q Title: <br /> ir­L--S <br /> Print Name: V rt�` 1 t 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 /> 4`1X 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: 1 <br /> Carrier: JVIC t. 1 t} Policy#: — Exp. Date: /0/1 <br /> //a/— <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' co pensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwit complywith th e p ovisions. <br /> Signature: <br /> Print Name: <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 /> AU HO ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, , hereby authorize <br /> Name d c lxeneed AuttwnxA Repneertunw /� AT-- <br /> P-1 Ne of Authar—d Awt <br /> to sign this San Joaquin Coun Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one y ar and is imited to;the work plan dated on the front page of this application. <br /> siwwun or C47 uthanb R&PMUM <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />