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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: <br /> f � � � '' { ! t�U - PERMIT SR#: <br /> XtfA / C <br /> LICENSED CONTRACTORS DECLARATION <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Crralif�onnia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: (A r <br /> �0.) —96[� t ta 4-,,— <br /> License#: Com; V ,s' Expiration Date:/ <br /> Signature: Title: ,_r4O/�t !!f►OGrr <br /> Print Name: C/�//'ll �G(/I Date: <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 /> �1 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: A01V Policy MR/C W0-/0W-30?-.XP.sp. 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 comp) th those provisions. <br /> Signature: <br /> Print Name: Gh/'/f P,�'mgel- <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, G47l�i!� c��,o_/ , hereby authorize <br /> +� x er,wd O(N a6wPlit Ome A.M-1-d ASOrd <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 lim' to work pla ated on the front page of this application. <br /> SiynOG6t Ot G67 Litanad AuMOn20tl eproxnmSw <br /> EHD 29-01 &23-2015 Site Mitigation Well Permit Application <br />