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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1e10 E.Hazelton Avenue,Stockton,CA95205 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: vaw Drarng.ME;. <br /> License#: C57 7209 Expiration Date: `mot <br /> Signature: Title: President <br /> Print Name: Karli R.Stroing Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 /> E3 provider}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 /> CXLabor Code, for the performance of the work for which this permit is issued. My workers' <br /> Cction ins ranee carrier and policy numbers are:Carrier. <br /> Policy#: Exp. Date: 1 <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 /> t fo hwith co ply with those provisions. <br /> Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' OMPENSATION 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 /> 7 <br /> AUT RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, hereby authorize in P.Lane,PG#6795 <br /> Nlrna o!C L red R dud Repree h! ,� dnt N—f A,.ha ri"d A,-J <br /> to sign this Sari oaquin County Well &Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one. r an is lire' d# the,work plan dated on the front page of this application. <br /> m p w— <br /> EH❑29-01 04-07-2022 Site Mitigation WeI118oring Permit Application <br />