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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _-Z313 CAsr e-f_R7ek WAY PERMIT SR# <br /> STOc_KTVff C'A <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chap er 9 (commencing with Section 7000) of <br /> Division 3 of the Cal tforrmla Business and Professions Code and i ny license is in full force and effect. <br /> License#: 3 Z E xp❑ te: 6/30/2012 <br /> Date-, Contractor: WDC Exploration&Wells <br /> /f �r /� <br /> Signature: <br /> �"x �� Title. <br /> Field Operations Manager <br /> I'rlllt Name: Kenneth B Cook <br /> WORKERS'COMPENSATION DECLARATION I <br /> 3 <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) I <br /> I -have and will maintain a certificate of consent to elf-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, forte performance of the work for which this <br /> permit is issued. <br /> j <br /> X 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: attached Policy Number: attached <br /> I certify that in the performance of the work for which t is 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, <br /> and agree that if I should become subject to workers'compensation provisions of Section 3700 Of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: attached Signature: <br /> Print Name' Kenneth B Cook } <br /> WARNING:FAILURM TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO 1 <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDr rION TO-THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ol C-51 licensed authorized representative), <br /> hereby authorize tprint name)R.'L.EW K!ARu, to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization Is valid for one year and Is limited to the work <br /> pian dated on the front page of this application. <br /> EHD2941 07Z2W6 WELL PERMT APP <br />