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SO/ Lion NlO San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: .S2/ No rk c lie/ pc+c Lavyl,, Jodi PERMIT WP#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. Contractor Name: Cal-Nev Geo Exploration License#: 1039188 Expiration Date: 05/31/2024 Signature: Nisi Title: President Print Name: Alisha Tadlock Date: 8/14/23 WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self-insure for workers' compensation, as E3 provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the ® Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: State Fund Insurance Policy#: 9289493-2022 Exp. Date: 12/21/2023 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, and agree that if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall //_'nI Q forthwith comply with those provisions. Signature: U N (�^�^�✓& Print Name: Alisha Tadlock WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION l Alisha Tadlock hereby authorize Steve Muir ff..0.5 L..W A.Unmr1red aeDresentegve Not tune of AuUnodeed Agent to sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. UK '10& 8lgnelvre of g31 Ownsed Autlomn.W eepresenfegv EHD 29-01 04-20-2023 Site Mitigation WeIlBofing Permit Application