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48/14/2007 10: 2E 923130302 <br />GREGG DRILLING Sw v a, �FAGE— 92 <br />08/13/2007 MON 13:55 FAQ0 j002.002 <br />_ q <br />San Joaquin County Environmental Health Department Unit IV W®ii Permit Application Supplement <br />JOB ADDRESS: UZ. Gt%c< <9 PERMIT 5R#: I <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I horeby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of bivision <br />3 of the Business and Professions Code and my )icense is in full force and effect. f <br />Ucenso ti: Expiration Date: <br />pate: ntract <br />Signature: Title; A <br />Printed name: _ <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm uncfv 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 <br />T by Section 3700 of the tabor Code, for the pertormance of the work for which this permit Is issued, <br />I have and will maintain workers' cQmpensation insurance, as required by Section 3700 of the Labor Code, <br />far the performance of the work for which this permit is isaued. My workers' compensation insurance <br />carrier and jLplicy numbers are, ( I <br />Carrier. 4�ArI � Poflcy Number: <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' compensetiOn laws of California, and agree that if 1 <br />should become subject to the workers' compensation provisions of Smction 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />�jJ <br />Expiration Date: O " Signature: <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 DAMAGES AS <br />PROVIDED FOR IN SF-CTION 3706 OF THE LABOR CODE. <br />THE, THAN C-57 SIGNING PERMIT APPLICATION <br />1, (signature ofC-ST tleons2d authorized representative), <br />hereby authorize (print Warne) E�� <br />1.. _ <br />to sign this San uaaquin County Well Permit Application on my behalf. I undQrztand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this appllcatlon. <br />s-29,02 i <br />E7 0 2V-02 -nn 1 <br />6/22fD4 <br />