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San J uin County Environmental Health Depatent i <br /> i <br /> WELL & BORINGl { lSUPPLEMENTAL <br /> f <br /> JOB ADDRESS: <br /> 17100 Murphark ay, LathrolD, CA 95330 PERMIT WP#:—d- <br /> LICENSED <br /> _ <br /> I hereby affirm that l am licensed under the provisions of Chapter 9 (commencing ith Sect on 7000) o <br /> Division 3 of the California Business and Professions Code and my license is in full force nd effect. <br /> i <br /> Contractor Name: Peneore Drilling <br /> License : C57#57 906899 Expiration ate: <br /> Signature: Title: <br /> Print Name: U ate: I <br /> WORKERS' COMPENSATION <br /> I hereby affirm under penalty of perjury one of the following declarations: 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 r which this <br /> permit is issued. <br /> I have and will maintainworkers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. y ` rers' <br /> compensation insurance carrier and policy numbers re: <br /> Carrier: voQS�� <br /> olicy#: Z ?C Exp. : <br /> I certify that in the performance of the work for which this er it is issued, I shall not emplo' any person in <br /> any manner so as to become subject to the workers' compensation la o California, and any <br /> that if l <br /> should become subject toworkers' compensation provisions of Section 3700 of the Labors Code, I shall <br /> forthwith comply it those provisions. <br /> I <br /> Signature: <br /> Print me: . IL <br /> WARNING: FAILURETI IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYERTO CRIMINAL PENALTl CIVIL FINES $J00,000, I <br /> ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION SIGNING 1APPLICAhON <br /> I, �tl� _, hereby authorize <br /> Feint Nemo®9 utWnWd Ogg@n¢ 3 <br /> C T en ua eeeenta4ive <br /> o sign is a o ui n ell ori it Applicationo y behalf. I understand' this <br /> authorization is valid for one year an is limited to the work plan dated on the front page of this application. <br /> d e a4 L}Gt � ri Rep n `ve <br /> EklLl 29-09 9-2097 Site Mitigation Well/Boringf�ermit Application <br />