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• '7777 -- , hereby authorize <br />Print Name of Authonzed Agent <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 />t C-57 Licensed AuthOnzed Representative <br />San ,,,,aquin County Environmental Health Deparwient <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 54 North Cluff Avenue, Lodi, CA 95240 PERMIT SR #: <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: Environmental Control Associates, Inc. <br />License #: 0-57 695970 Expiration Date: /3D/16 <br />Signature: <br /> <br />Title: Owner <br />Print Name: Tim Tyler Date: 6/20/2017 <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 />cornpensation insurance carrier and policy numbers are: <br />Carrier: •L) Policy #: Exp. Date: <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 />Signature: <br />Print Name: <br />7--7 <br /> <br />Ty L <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 />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application