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San Joaquin County Environmental Heaith Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:_ .•r � ��•G 7W AC�i'N/��1% 5 r_ PERMIT SR <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 Califomia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: <br /> License#: 7�- .< 5 Expiration Date: March 2018 <br /> /I <br /> Signature: ...L �� Title: <br /> Print Name: _ 77 5 M ���? S/3UiZL --- Date:__"&IL. 9 2—e -- <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 /> O 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 worts for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: American Interstate Policy#: AVWCPA2557252016 Exp Dom: 12/19/2017 <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 tabor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: la— <br /> Print <br /> Name: -- <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 /> I, hereby authorize 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 pian dated on the font page of this application. <br /> - ---- ------- - -- -- - <br /> EHD 20-016-23-2015 Site Mitigation Well Permit Appkation <br />