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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />920 Frewert Rd, Lathrop, CA 95330 <br />JOB ADDRESS: APN 191-260-22 PERMIT SR #: <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 California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: California Pacific Drilling <br />License #: Expiration Date: 07/31/2017 <br />Signature: Title: Owner/Operator <br />Print Name: Elliott D. Vande Poppe Date: 08/29/2016 <br />WORKERS' C-„�OMPEF16TI!2N 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 workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: Admiral Insurance Company Policy #: 9098420-16 Exp. Date: 05/05/2017 <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: <br />Print Name: - Elfiott D. Vande Poppe <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-67 SIGNING PERMIT APPLICATION <br />I, , hereby authorize <br />Nam C -s7 Lkan .oe,... tauw vont name a A gent <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 />SWWtwe of C37 licoinstC as epr—tawe <br />C�[#F*1#1 r-P*1 11W <br />Site Mitigation Well Permit Application <br />