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SR0084680 (3)
Environmental Health - Public
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DR MARTIN LUTHER KING JR
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2900 - Site Mitigation Program
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SR0084680 (3)
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Entry Properties
Last modified
10/14/2022 11:01:32 AM
Creation date
10/14/2022 10:56:41 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
WORK PLANS
RECORD_ID
SR0084680
PE
2903
FACILITY_ID
FA0024463
FACILITY_NAME
ALL MINI VANS AND MINI TRUCKS AUTO DISMANTLER
STREET_NUMBER
930
Direction
E
STREET_NAME
DR MARTIN LUTHER KING JR
STREET_TYPE
WAY
City
STOCKTON
Zip
95206
APN
16718303
ENTERED_DATE
1/3/2022 12:00:00 AM
SITE_LOCATION
930 E DR MARTIN LUTHER KING JR WAY
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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EHD - Public
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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 930 East Dr. Martin Luther King Blvd. PERMIT WP M <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: AdvancedGeo, Inc. <br /> License #: 1063735 Expiration Date: 02/28/2022 <br /> Signature: Title: <br /> Print Name: Evan Schmidt Date: 12/27/2021 <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 /> 0 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 /> Carrier: TRAVELERS PROPERTY CASUALTY Policy#: UB7J592196 Exp. Date: 10/17/2022 <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 to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: Robert E. Marty <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 /> hereby authorize <br /> Name of C-57 Licensed Authorized Representative Print Name of Authorized Agent <br /> to sign this San Joaquin County Well 8t 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 /> Signature of C-57 Licensed Authorized Representative <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />
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