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1DEC. 19' 20061.1 5: 56PM 92537PARSON S-925-979-9781 GREGG DRILLING NO, 5 10 3 IP, 4 06 <br /> 10ub 4;111 •HSUNS-925-919-9781 N0, 5058 P. 3, <br /> San Joaquin County Environmental Health 0sj7artment Unit IV Well Permit Appllcatlon Supplement <br /> JOB ADDRESS: +o(� , ..� . . ocJir-4PERMIT SR#: <br /> f <br /> l' <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divislon <br /> 3 of the Business and Profta,"In—Cade and my license is In full force and effect, <br /> License#: to 54- :/C7 Expiration Date; /0 W J� <br /> Date; j�_" Contractor. �' D r� t ►� <br /> Signature: <br /> Printed name: f"�C <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 provided for I <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are' n <br /> Carrier: r(� Policy Number. <br /> I certify that In the performance of the work for which this permit Is Issued,I shall not employ any person m <br /> any manner so as to become subject to the workers'compensator laws of California,and agree that.If I i <br /> should become subject to the workers'compensa'on provisions of Section 3700 of the Labor Code,I sl Ell <br /> forthwith comply with those provisions. I <br /> i <br /> Expiration Date: ) 07 Signature: <br /> Printed Name: qA)K(Jen <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE lS UNLAWFUL.,AND 8NALL S41R3 n <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ' <br /> (1100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAa e$AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FOR THER THAN C-57 SIGNING PERMIT APPLICATION <br /> t' (algnetureafC•57 licensed authorized representative), <br /> hereby authorize(print name) f I <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this apppeat(on. <br /> 0.29.021 MI <br /> EHD 29-02-001 <br /> b/22)(A <br />