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i' WELL PERMIT APP EHD 29-01 07/20/10 s a -- I s San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL E . -1-5 landscaped right of way, Southbound on-ramp at W.Charter Way, Stockton" PERMIT SR# J08 ADDRESS: LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and rry license is in full force and effect. C-57 4a5-165 Exp Date: 31 January 2013 License#: Date: 16 October 2012 Contractor: Gregg Drilling I Signature: Title: £ Print Name: Chris Pruner WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. f I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers' € compensation insurance carrier and policy numbers are: Carrier:-,4-0 �0 Policy Number: /T C` LA 0 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, and agree that if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those pr4UNLAWF s Exp. Date:�I I Signature: I Print Name:WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGND SHALL SUBJECT AN EMPLOYER TO i CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, i ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. gUTHORI ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION Q / .i I, (signature of C-57 licensed authorized representative, hereby authorize(print name) Lisa Kullen ,to sign this San Joaquin County Well&Boring Permit ApWication on m behalf. I understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. l EHD 2101 0720110 VVELL PERMR APP I;