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San Joaquin County Environmental Health Department <br /> WELL He BORING PERMIT /APPLICATION SUPPLEMENTAL <br /> To30 S. G.E . D1Xoht ST. t 5TocKroN <br /> JOB ADDRESS: 50 0 0 5. A (R P O R T WAY , sTo c K To N * PERMIT SR#: <br /> * Pao7P_Cr A00PFSS <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 Code and my license is in full force and effect. <br /> Contractor Name: n l 61 t VVI- <br /> License#: 9 Expiration Date: LA 15/10 f`� <br /> Signature: Title: �b) <br /> Print Name: Date: (� Z <br /> WORKERS' COMPENSATION 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 /> 0 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 /> compen$atio insurance carrier and policy numbers are: _ <br /> Carrier: Policy#: 1150�' �)S Exp. Date: !J <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 becprfie subject to thework rs' compensation law of California, and agree that if I <br /> should become subject to workers' compensation rovisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply th those provisions. <br /> Signature: <br /> Print Name: ✓ l Y <br /> WARNING: FAILURE TO SECURE WORKERS'.C MPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYE TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COS,YO COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTI N 3706 OF THE LABOR CODE <br /> AUTHQRIZbTION FOR 04ER THAN C-57 SIGNING PERMIT APPLICATION <br /> ` .TOSEPH RAMAGE <br /> I, , herebyorize RAMAGI: ENytRor{MENTAL . (NG. <br /> "N.— Lice ed Authori Represenative tPrint Name of Authorized Agent <br /> to sign this San Jo uin County ell & Boring Perrirk <br /> plication on my behalf. I understand this <br /> authorization is valid for one yepr d i mit6d to the wlan dated on the front page of this application. <br /> "A) V\� <br /> i re Li ed Autho epresentative <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />