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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 2600 W Yosemite Ave. PERMIT WP #: <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: Middle Earth Geo Testing Inc. <br />License #: 0 T%'Ll 5 <br />Signature: <br />Print Name: <br />Expiration Date: 13c, <br />Title: / 1 KaJ�c rCi <br />Date: Ad <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 />_ compp-nsatinr_ansurance carrier and policy numbers are: <br />Carrier:' e n Policy #: -ZC7 I"J 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 becoqle subject to the workers' compensation law of California, and agree that if I <br />should become subject to rkers' compensation provisions of Section 3700 of the Labor Code, I shall <br />.. forthwith cQmpl"ith those provisions. <br />Signature: <br />Print Name:. <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 />1, , ,R hereby authorize Megan Murphy <br />me of C•57 Licensed Au rued Representative Print Name of Authodud Agent <br />to sign this San Joaquin County Well Borin"ernr,,4'Application on my behalf. I understand this <br />authorization is valid for one year and is lim�i w�c��an dated on the front page of this application. <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />