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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: Central Parkway PERMIT WP #: <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: <br /> <br />Pri\\i C., • <br /> <br />License #: ci <br />Signature: Title: C 0 <br />Print Name: Date: <br />WORKERS' COMPENSATION COMPENSATION DECLARATION <br />1 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 />D// 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: \,./ es ,-(c.) TA3 Cio Policy #: Exp. Date: V 1 1 1 <br />1 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 t94vorkers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. 2 <br />—Tvcal t\bile,-,7 \ <br />WARNING: FA LURE 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, Tic.,N. N Jq ttz-Ns_ , hereby authorize kc•V\ 90r0 e/ <br />Name of C,S7 Liven tinzesi Representetve Pr blt Name of Authorized 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 an,dis limited to the work plan dated on the front page of this application. <br />y,,,e---L.,-------____ <br />Signatuns of C.57 Llunsed Authorized Representative <br />Expiration Date: <br />Signature: <br />Print Name: <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application