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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: S03 2 l.Jra,,kw C,•, -J PERMIT WP#: <br /> oc�c�u� CA �i5Zv5 <br /> i <br /> LICENSED CONTRACTORS DECLARATION <br /> 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: 1 ro�L i <br /> License M -7-yqr Expiration Date: 03/31/2026 <br /> Signature: Title: Owner/Ceo <br /> Print Name: Dennis Ott Date: 01/11/2026 <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 /> 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: State Farm Insurance Policy#: 90-E7-V440-7 Exp. Date: 03/15/2026 <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 b me subject to t Se workers'compensation law of California,and agree that if I <br /> should become subje workers'c nsation provisions of Section 3700 of the Labor Code, I shall <br /> fort i comply with those provisions. <br /> Signature: <br /> Print Name: Dennis Ott <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 /> 1, Dennis Ott ,hereby authorize Bryan Yates with Apex <br /> ,—u a Cdnlae„d Aub%orbd Rapr...n, . p., ,,,,. edad Aa-t <br /> to sign this San Joaquin Cou Well&Bo It Application on my behalf. I understand this <br /> authorization Is valid for one year d is 11 fie work plan dated on the front page of this application. <br /> ,tune Cdl , ,d R,plu,nULN, <br /> EHD 20-01 07-01-2025 Silo Mlllgollon Well/Boring Permit Applicalion <br />