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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> }251 S . C.rc , 01X0N ST., STochToN <br /> JOB ADDRESS: S 0 0 o S. A I K F 0 R T WA-f , 5 To c h To IS PERMIT SR#: <br /> * FRoJEc-r RpORl�_SS <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 theCalifo ' Business and Professions Code and my license is in full force and effect. <br /> a <br /> Contractor Name: <br /> ` w <br /> WC <br /> License#: V 01V Expiratio Date: L4 JO <br /> Signature: , Title: / <br /> Print Name: Ill- Date: <br /> WORKERS' COMP SATION 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 /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> com en ation insura ce carrier and policy numbers are: <br /> Carrier: Policy#: Exp. 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 to the workers' compensation law of California, and agree that if I <br /> should become subject to work rs' compensation provisions of Section 3700 of the Labor Code, I shall <br /> rthwith comply w)th those provisions. <br /> Signature: <br /> Print Name: 1i _ <br /> WARNING: FAILURE TO SECURE WORKERS' O PENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDI7tQN TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PRO DED FOFt\iN SECTION 3706 OF THE LABOR CODE <br /> UT ORIZATION R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 11 -TOSt FH RAMAG� <br /> I, A 1 her byauthon KAMA6E ENvIRoNMENTAI IN <br /> Name of -57 nse oziied epnt ntati a Print Name of Authorized Agent <br /> to sign this San oaquin unty Well & �orin Permit Apphcat,on on my behalf. I understand this <br /> authorization is'v ' for one ye r and . li to he work plan dated on the front page of this application. <br /> Signa m of C-57 L e A o s tative <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />