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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOE ADDRESS:_6471 Pacific Ave,Stockton,CA 95207(near 236 Lincoln center) _ PERMIT WP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> 1 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: xic&xG Dr, <br /> License#: IV _Expiration Date: I l �-zeZ'A <br /> Signature: Title: Cr Q <br /> Print Nam, . --i-uGP1 /V�y �� Date. ZC'Z <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 /> 17 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 /> 0 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 /> (-� <br /> Carrier: ,SCS� _ Policy#:_ '�L�` -_ 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 the workers' compensation law of California, and agree that if I <br /> should become subject to orkers'compensation provisions of Section 3700 of the Labor Code, i shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: v P.✓ <br /> WARNING: FAIL. RE 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, hereby authorize I V 1G��� <br /> y,y d.-!]lr���Klto.f� n» -- Print Nana Mrlle«izna Gpvni <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 this application. <br /> EHD 29-01 8-1.2017 site MRigatlon well/Boring Permit Application <br />