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San Joaquin County Environmental Health Department <br /> WELL Sr BORING PERMIT APPLICATION SUPPLEMENTAL, I, !(� <br /> JOB ADDRESS: 306 North Ham Lane, Lodi, CA 95252 PERMIT WP#: V`r 1 00 44'S 6 �-- <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: Environmental Control Associates Inc. (ECA) <br /> License#: 695970 Expiration Date:9/30124 <br /> Signature: /w""a Cee.E Tale: General Manager <br /> Print Name: Bryan Cook Date: 5/2/2023 <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 /> M 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: Policy#: 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 Calffomia, and agree that if I <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> ,yam forthwith comply with those provisions. <br /> Signature: 4{l'G 14&- <br /> Print Name:Michel Helou <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 /> 1, Bryan Cook ,hereby authorize Michel Helou <br /> to sign this San Joaquin County Well S 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 0420-2023 Site Mitigation WeIVBoring Permit Applicatlon <br />