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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1423 Bradford Street , S j,,k�an PERMIT WP #: <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: TEG-Northern California <br /> License#: 706568 Expiration Date: <br /> Signature: h&Z Title: R/11 p <br /> Print Name: -Ma r k jq_rpl�lct k Date: 7/2 y/j q <br /> WORKERS' COMPENSATION DECLARATION T <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 fol- 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: <br /> re:Carrier: MarfFord Policy#: 72WF0_L) 997.3 Exp. Date:/O / <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 I <br /> should be:r7, <br /> provisions of Section 3700 of the Labor Code, I shall <br /> rthwith com with those provisions. <br /> Signature: <br /> Print Name: '`^1=s" �� <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 /> A r J -o-rp Lrx k hereby authorize JV/r,0 1A o �r 6 <br /> Name of 37 Lieen ed Authonz d Representative Prinl Name of AutAorized Agent <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 /> yo�z< <br /> Signature of C.57 Licensed Authorized Representative <br /> EHO 29-01 B-1-2017 Site Mitigation Well/Boring Permit Application <br />