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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:Stoodus rash. an a. ,.nli_Aimed PERMIT SR III <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed miner the proNsinos of chapter g (commencing with Section 7000) of <br /> Division 3 athe Carimmia Business and Processions Cade and my license is in fail force and affect <br /> Comrautoriname: MRDriIIing <br /> Lkense # 7irbirfol Expiration Date: 09I1 <br /> Signature: � 2%r[_ Title: HMO <br /> Print Name: Steve Molest Data 101i <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally of pe0ury one of the falesumn declarations: (check one) <br /> I have and will maintain a earnings of consent to sell Insure for workers' compensation, as <br /> D provided for by Seaton 3700 of the Labor Code, for the performance ofthe work for which this <br /> pound is issued. <br /> M, I have and wall maintain warders' compensation insurance, as required by Section 3700 athe <br /> Labor Code, far Me performance of the work for which this permit is issued My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carder: SW51mebbeimwl Insurance Co. Poticyit. T10231307 Exp. Date: 0 <br /> caddy that in the performance of the work forwhich this pendd 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 o0ce that if I <br /> should become subject to workers' compensation provisions a Second 3700 of the Labor Code, I shall <br /> Ferm h comply with 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 F100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEYS FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE <br /> AUTHOROATION FOR OTHER THAN CST SIGNING PERMIT APPLICATION <br /> is hereby authorize <br /> to sign this San JoaquinC County Well n Boring Permit Application on my behalf. I understand this <br /> aaM1ormnon is valid for one year and is limited 0the wont plan dated on the fount page a this application. <br />