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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> , f pp <br /> JOB ADDRESS: /ft� � �(— '�✓� `+ �' /av(e PERMIT "#: QQ IN -76,b <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: <br /> License#: q q - Expiration Date: ! <br /> Signature: _ Title: fie. �) \3�� t.C2mil. 1�C—c� <br /> Print Name: A-�2_7l VA_ �--��� _Date: � Zp Z� <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: � �t4� c£5 °� Policy#:l,,,&?AgI V 36,5;,Y�.�Exp. Date: B ! -O <br /> LcL�jL &- Mperre f}f 'Pklp� <br /> I certify that in he 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 1 <br /> should become subject to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwitK imp with those provisions. <br /> Signature:_,2c- 4tp r,�, <br /> Print Name:4- Ttr( <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 /> hereby authorize 5-f' keAj G • <br /> Nam.of Cal'Ucensatl Autlwrlead Rairdnf kfiMo t -to sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this <br /> authorization Is valid for o77FZE <br /> ton dated on the front page of this application. <br /> im tativa <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit g Application <br />