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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 5;-- i1gsi— <br /> <br />iLa24z, S RMIT SR # <br /> <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: U\'W(0 0 Ov1 01_0 -17\-- <br />License #: '()44(e);Y:\ Expiration Date: NO\I <br />Signature: Title: <br />Print Name: (A-i:t;VA Date: PC <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, fo - the performance of the work for which this <br />permit is issued. <br />I have and will maintain workers' compensation insaance, 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: <br /> <br />Policy #:( : Exp. Date:2,11 <br /> <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 Labor Code, I shall <br />forthwith comply with those provisions. <br />_ • <br />Signature: <br />Print Name: <br /> <br />C <br /> <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 /> - <br />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 plan dated on the front page of this application. <br />' <br />Signature of C-57 tIceneetAulhortzed Repres•ntative <br />7 <br />, hereby authcTize <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application