Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS : 9999 S . Austin Road , Manteca , CA 95336 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: Landmarc Environmental System <br /> License #: 1032403 Expiration Date : 11 /30/2025 <br /> Signature : Title : Principal <br /> Print Name: 7;Ce Rau Date: 10/23/2023 <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 /> 13 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 /> M 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: New Hampshire Insurance Co . Policy #: WC014195884 Exp. Date: 05/01 /2024 <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 workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signa e: <br /> Print Nam a Rau <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 /> I, , hereby authorize <br /> Name me-57 Licensee Authorized Representative prim Name of Authorized Agent <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 /> Signatme of C-57 Licensed Authorized Representative <br /> EHD 29-01 04-20-2023 Site Mitigation Well/Boring Permit Application <br />