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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS:VVA <br />n1 111E rt -1 PERMIT SR #: <br />Cf <br />0 , �N OD <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: r `V1 `' V <br />License #: 1 C 1 Expiration Dat <br />Signature: _ Title �icS - L) <br />Print Name: I ip 1 Date. <br />TION DECLARA <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 />Ex�) 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 />comensation in rice carper and policy numbers are: <br />Carrier: J 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�,"orkers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisio of Section 3700 of the Labor Code, I shall <br />forthwit comply with those p ovisions. <br />Signature: <br />Print Name. <br />WARNING: FAILURE TO SECURE WORKERS"G-6MPENSATION 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 />AUTHOMZATION FOR OTHER THA <br />hereby authorize <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one y ar and is imited to the work plan dated on the front page of this application. '10 yJl_ � �M'l I i �,� <br />4 <br />EHE 29-01 6-23-2015 Site Mitigation Well Permit Application <br />