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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 950 Stewart Road PERMIT WP M <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: Bradley and Sons Drilling and Pump Systems <br /> License#: 414178 Expiration Date: 3/31/2024 <br /> Signature: _Title: <br /> Print Name: �� —- Date: <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 /> 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: Berkshire Hathaway Policy#: BRWC329428 Exp. Date: l._/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 I <br /> should become subject to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with th e provisions. <br /> Signature: <br /> Print Name: 10p <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 /> Narrr_of C-51 License)Au7troriml Nege�enlative Pnnl Nam of P.ut row rcA lgen7 <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 /> ..-__..-__-_ __--____ {prs re - Qcenxd7Sulliorfis3ReprexnSalive <br /> EHD 29-01 04-07-2022 Site Mitigation Well/Boring Permit Application <br />