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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _ zo:� CUyy)tL-1 CI V6 9)Nj. 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 <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License 4: 938110 Exp Date 09/30/15 <br /> Date: 0 2 2 014 Contractor: Cascade Drilling, L. P. <br /> T-' <br /> Signature: �fwTitle: General Manage- <br /> Print <br /> ana erPrint Name: Pair 1 Gne 1 aro T <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 /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <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: Zurich Policy Number: WC013734400 <br /> I certify that in the performance of the work for which this permit is issued, I shall nat 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 Section33 of <br /> the Labor Code, I shall forthwith comply with those Provisions. <br /> Exp. Date: 10/02/2015 Signature: <br /> Print Name: Paul Snelgrove <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,ANS[ZAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> M, N <br /> A„ 14r)IQ17ATInh1 FnR O ER THAN-C 57 SIGNING PERMIT APPLICATION <br /> I, Paul Snelm-ove ,777'��� _ �� (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name)Bridget Floyd 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 /> plan dated on the front page of this application. <br /> EFID 7.9-J1 05/09/12 <br /> WELL PERMIT APP <br />