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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: eeneath 1-5 from W Fremont St to W Weber Ave and Its vicinity PERMIT W P#: 2-6 D 2/ <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: Geocon Consultants, Inc. <br /> License#: C57, 716050-A, HAZ Expiration Date: 12/31/2025 <br /> Signature: � Title: Construction Services Manager/RME <br /> Print Name: Robert M. Kimball Date: --.917 ZOo21 <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 /> C3 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 /> 'a Labor Code, for the performance of the work forwhich this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Transportation Insurance Co. policy#: WC679910107 Exp. Date: 1/1/2025 <br /> 1 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: /Vlew lop:, <br /> Print Name: ROBERT M. KIMBALL <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 /> l ameelCS/L o<me Aul�ortae NeprtaenhMa pM,llameol AUNaXeW Agent <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 /> 519naNraW b57 rhenaeX AQMorLzaRapresen,a a <br /> EHD 29-01 04-20-2023 Site Mitigation WelllBoring Permit Application <br />