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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:`�(p�2 ��5� WG ��o0 2�� � PERMIT WP M <br /> S\,cvk' vo,, cA et s-ZoJ <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 /> Contractor Name: 1;�., Pale <br /> License#: C- 1 zy ' Expiration Date: 03/31/2026 <br /> Signature: Title: Owner/CEO <br /> Print Name: Dennis Ott Date: 1/11/2026 <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 /> 13 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: 03/1 S/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 t become su ect to the workers'compensation law of California, and agree that if I <br /> should become su ect to work s'compensation provisions of Section 3700 of the Labor Code, I shall <br /> ith 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 /> Dennis Ott DBA Enprobe Inc ,hereby authorize Bryan Yates with Apex <br /> Nu O CL,Lk4n..d AuearU.d N.pru.nt,W. PMt N,m.er AuU .d Agml <br /> to sign this San Joaquin Cotn t Woll 8t Bo I g Permit Application on my behalf.I understand this <br /> authorization Is valid for one year d is Illnit work plan dated on the front page of this application. <br /> eree,t a sr run,w n.pn,.nu . <br /> EHD 2.0-01 07.01-2025 Slto Miligallon WolVeodrig Permit Application <br />