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i <br /> I <br /> I <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <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 l <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. I <br /> Contractor Name:Penecore Drilling Inc. <br /> License#: 0 °l Expiration Date: Z( <br /> Signature: Title: Cr0 <br /> Print Nam vy 1A Date: e-�2S-2 <br /> ) <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 work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: 9 <br /> Carrien. Scl I Policy#: ��S`� - 207,0 Exp. Date: 8 a G 2Z <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 <br /> should becomZ7,/f--N <br /> mpensation provisions of Section 3700 of the Labor Code, I shall <br /> ith comply with those provisions. <br /> Signature: <br /> Print Name: <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-67 SIGNING PERMIT APPLICATIOt iN <br /> I, GYM &Vjcd� ,hereby authorize ,r w\ \L� <br /> Nam v r-b7 uoe""�A�ftftafw Repn e nuave Pant Name of Now-a P4- <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.1 understand this <br /> authorization Is valid for one year d is li "te o the work plan dated on the front page of this application. <br /> Nu oTC3TlJc�RUNozIzM MprnantaUra <br /> 6 <br /> EHD 29-01 5-1-2017 Site Mitigation WellBor ng Permit Application <br />