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efff 44111 VO <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: AO- kTN\ 3051 S,E1 Indy ,516,1 PERMIT WP #: <br />5 tr,cic IvY\ <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: <br />License*: Expiration Date: 1] t•4ea.1 <br />Signature: Title. <br />Print Name: t3 Date: Z 13-N acy <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 />e.0 <br />Carrier: :-/LoR ArjL14.4,.s . Lc Policy #: Exp. Date: IS1 I ISLA", ,..f/V 1 <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: Girke-tS esi <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 />I, .,,..1412:5 , hereby authorize ,7c04i-tric <br />Jal* of G -54 1.1.n.r1 Rap • f •ntnnva PrInt orAwnorawyluirm <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 thls application. <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application