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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Sotith Corral Hollow Road, Tracy, CA, 95304 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: is <br /> 20Ljzg <br /> License#: C S 7 y g,l 1.6 <br /> S Expiration Date: �© <br /> Signature: �.n -z Title: O�/u O/!1 /IM0,94dd <br /> Print Name: Chr// Peewo7 e- Date: "7�21'//a <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 /> 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: T ( T S/oeG/ Policy#: WCO 2TX-,48'/•ArExp. Date: 9 3/ <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 /> Signature: / XZ, <br /> Print Name: .,yn Pe - <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, C Pry ALA hereby authorize _- <br /> u,uaF IGfl Lfcan,ed lw e,4m RrMrmbN'e P�rmo ,Ywl Apenl <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 k pl�tia ecl on the front page of this application. <br /> yn.W1e�<f L�.�u1M�tT�i Rrpmmltl s <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />