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EHD 29 01 07/20/10 WELL PERMI7APP7 <br /> San Joaquin County Environmental Health Department <br /> WELL &BORING PERMIT APPLICATION SUPPLEMENTAL <br /> South Stockton St, W 2nd St, and W 3rd St, Stockton, CA 95206 <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) ;- <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of 4A <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> 9 <br /> License#: C-57 485-165 Exp Date: 31 January 2013 <br /> Date: 18 June 2012Contractor: Gregg Drilling <br /> i <br /> 1 � , <br /> Signature: tr Title: iL�/"�1flGY�r <br /> Print Name: Chris Pruner t <br /> l <br /> WORKERS' COMPENSATION DECLARATION - <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 7PP� kR <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. c <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., Policy Number: <br /> I certify that in the performance of the work for which this permit Is Issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and s <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 13�T/ l 7 Signature: --� <br /> j Print Name: ��i� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, _ <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> IZAT FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, > (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Lisa Kullen ,to <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD29-01 07MOMO - WELL PERMITAPPt;.,;. <br /> r <br />