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JOB ADDRESS: <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />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: Penecore Drilling, Inc. <br />License #: 906899 <br />Expiration Date: 11/30/2018 <br />Signature: <br />Title: CEO <br />Print Name: Tu Nguyen <br />Date: 12/13/2017 <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 wor ers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: Westco Insurance Co. Policy #: WWC3218776 <br />Exp. Date: C 8/01/2018 <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 ag lIee that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Cdde, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Print Name: *anNguyen <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 />Tuan Nguyen <br />Name of Licensed quMOnznd Rcpresentanvc , hereby authorize Chris Drabandt <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I­ <br />zunderstand this <br />authorization is valid for one year and is ' ited to the work plan dated on the front page of this application. <br />&gnaturo of C 7 Licensed Authonzed Repiosentaeve <br />EHD 29-01 8-1-2017 <br />Site Mitigation Well/Boring Permit Application <br />