Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Zt�6OI V\,c6��� E _ _ 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: cascade Drilling <br /> License#. 938110 // ,, _ Expiration Date: 9/3 0/17 <br /> Signature: �. l tL (_ ---Title: operations Manager <br /> Print Name: Kenneth B. cook Date: 3/30/17 <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 /> 13 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: on file 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 workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: �. Coil <br /> Print Name: Kenneth B. Cook <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 /> Kenneth 13. Cook , hereby authorize <br /> hnmf-f_CV Leonsea m am aproxnren. -- "F�ne Hance of�no.rw n ., <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 /> Cate— <br /> `1pn Nuro el �AlllhO—d rpror,n Whv <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />