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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 1120 Frewert Rd, Lathrop, CA 95330 <br /> JOB ADDRESS:APN 191-270-05 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 Professions Code and my license is in full force and effect. <br /> Contractor Name: California Pacific Drilling <br /> License#: 76640211 Expiration Date: 07/31/2017 <br /> Signature: 22���/� =.- i Title: Owner/Operator <br /> Print Name: Elliott D. Vande Poppe Date: 08/29/2016 <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 /> 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: Admiral Insurance Company Policy#: 9098420-16 Exp. Date: 05/05/2017 <br /> 1 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 1 <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> ``__ forthwith comply with those provisions. <br /> Signature: fi 09SidQ 4)a -- <br /> Print Name: Elliott D Vande Poppe <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, , hereby authorize <br /> „xo W.�W AUMv�J WAWMO RYINm of/ Y�1 <br /> to sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br /> Sy m01 C."—"AUX w W� <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />