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San Joaquin County Environmental Health Department <br /> WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 25775 South Patterson Pass Road,Tracy,California 95377 PERMIT WP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: Gregg Drilling and Testing <br /> License#: C.S7 --Expiration Date: <br /> Signature: Title: <br /> Print Name: C�J/�� /'G�/j�� Date:— <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 self-insure for workers' compensation, as <br /> E3 provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> t/ 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: �/ �j <br /> Carrier: �� S;�rrrlr�y Policy#: kx-- 02_�Jpl 'o Exp. Date: ��3/ A? <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers' compensation law of California, and agree that if I <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwit omply with those provisions. <br /> Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> r��AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, rril P"u/1/1 , hereby authorize <br /> Name of C-57 Uf aad AuthmU NepM1MM�dv� print Name of Authoriz�d Agent <br /> to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one year and is limited to t e work an ated on the front page of this application. <br /> 8 nol—of C-57 UJ aad Aolhuel d Rdpnnerdeflw <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />