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08/03/2006 15: 10 9253130300 GREGG DRILLING PAGE 02 <br /> aUli. J 2U0b 9:�6ANI OONS-925-979-97/81 <br /> N0, 4416 .__P. 2;2 <br /> San Joaquin County environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: r roR; 4+ <br /> r' et" <AERMIT SR#: <br /> �O' Amro' .1 D G.ccrp o Jko� <br /> � M,_ <br /> LICENSED CONTRACTORS DECLARATION (LD) <br /> I hereby affirm that I am licensed under the provfsiens of Chapter 9(commencing with Sectfon 7000)of <br /> 3 of the Business and Profeasions Code and my license is In full force and effect. <br /> License#:- 5- 0 6 <br /> Expiration Date: <br /> Date: 1 '1�' /� l <br /> Contractor. [� <br /> 5lgnature: <br /> Title.: .. <br /> Printed name,, <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 serf-insure for workers'Compensation,as prcvided for <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 polic numbers are' <br /> Carrier; / <br /> r Policy Number: <br /> I certify that in the performance of the work for which this permit la issued, I shall not®m l0 2r+, Pr`,. <br /> any manner so as to become subject to the workers'c�mpens>9tion laws ofA y y p' `i' fir' <br /> should become subject to the workers'compensation provisions of Section 370 nla, and agree the I shall ` <br /> forthwith comply with those provisions. <br /> EXpiration Date:-'' 7Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND bAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. AJ <br /> f (signature ofC-67 licensed authorized representative), <br /> Lone <br /> by authorize( i t name) <br /> gn this San Joaquin County Well permit <br /> Application on my behalf. I understand this authorization is valid for j <br /> (1)year and is limited to the work plan dated on thefrontpageofthis application. <br /> 02/Mf <br /> F-WD,Zu-02-001 <br /> 6/22/p4 <br />