Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS : 122 N . Wilson Way Stockton , CA 95205 PERMIT WP # : <br /> LICENSED CONTRACTORS DECLARATION <br /> 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 : Encon Technologies , Inc . <br /> License # : 748576 A- HAZ , C57 Expiration Date : 4/22/2022 <br /> Signature : Title : President <br /> Print Name : G . Joseph Scatoloni Date : 12 /29/2021 <br /> WORKERS ' COMPENSATION DECLARATION <br /> 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 /> 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 : State Compensation Insurance Fund Policy # : 9066107 - 2021 Exp . Date : 1 0 1 2023 ' <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 <br /> should become subject to worke s ' compensation provisions of Section 3700 of the Labor Code , I shall <br /> ort ith comply with those provisions . <br /> Signature : <br /> Print Name : G . 6oLeph Scatoloni <br /> WARNING : FAILURE TO SECURE WORKERS ' COMPENSATION COVERAGE IS UNLAWFUL , AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $ 1001000 , 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 , D a �� c�► M1tcg2g1r , hereby authorize st\ �' 04o � � <br /> Name of C-57 Licensed Authorized Representative Print Name of Authorized e t <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 /> Signature of C-57 Licensed Authorized Representative <br /> EHD 29-01 8 - 1 -2017 Site Mitigation Well/Boring Permit Application <br />