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i <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: 101 Plest Lathrop Road, Lathrop, CA 95330 PERMIT WP#: 2 ' 1 <br /> ` D O 2( 3 <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: ENC4M TFclit4OLOCalFi7,3NG. <br /> License#: 74`d 5-1 tp Expiration Date: 40/20 <br /> Signature: Title: E14alaot4MRMoPePA1V 5 Mw1Z• <br /> Print Name: A. ORV ID SPrI rA7,kR- Date: C1 101sq <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:syATECOM1?fW- noNz5UeMJcE Policy#: golp(o1072o2y Exp. Date: 1125 <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: - s .a <br /> Print Name: Michel Helou <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, A•DAV1D 13ALrA-ZA-P— hereby authorize Michel Helou <br /> Nam.arC47Lhenud AVUroarad aeproaanlalM P MH.m.oFAWW,M M <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 /> s9oalEoe�sltlanaea ne,4 a.pruml.Wa <br /> EHD 29-01 04-20-2023 Site Mitigation Well/Boring Permit Application <br />