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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> i <br /> i <br /> JOB ADDRESS: 3032 Waterloo rd, Stockton CA 95205 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 /> Y <br /> Contractor Name: Penecore Drilling Inc. <br /> License #: d(,7 °l Expiration Date: 30- Z 1 <br /> Signature: Title: Cr <br /> Print Nam 1UAO MVqI-A Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing 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 I <br /> permit is issued. <br /> .., / i have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> M� Labor Code, fear the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers <br /> 0}are, <br /> Carrier: �C C Policy#: 92 0 1 ! �, 3 - 2020 Exp. Date: 8 � a <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 Pworkers' compensation provisions of Section 3700 of the labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature:. <br /> Print Name: —Tucxil <br /> WARNING: F ILURE 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 APPAk <br /> LICnATIO},N <br /> 1, VGY1 , hereby authorize GAS , &/- r�` <br /> M Av"10,(\c•67 t C*ns Repmw a PAnt N.of Mh.I-W Plnmi <br /> to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br /> authorization Is valid for one year d is 11 'to o the work plan dated on the front page of this application. <br /> ku of C3T Lk*med Aifl iftodRopmentattwre <br /> EHD 29-01 8-1-2017 Site Mitigation We11113oring Permit Application <br /> , <br />