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Sent By: Gregg Drilling & Testing `nc. ; 925 313 0302; Jul-27-�' 16:14; Page 2;2 <br /> San Joaquin County Environmental HeaNh Services,Unit IV W 1��PemtIt Applici tion Supplement <br /> JOB ADDRESS: 029i, <br /> P :RNII�SR#: Cb 2�0 I 6 <br /> 3�r �-s(�e r� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions or Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and professions Code and my license is in full force and effect. <br /> License lf' t1iS lD O 7 Expiration Date: �- <br /> Date: �Io�7I D / Contractor, t' fG)A � : <br /> Signature: �dtitle: <br /> Printed name: rL moa k(e rL- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issuedjzi�l . <br /> have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. l G _ e a,r r Policy Number: WG , iS�O(g S�loT� <br /> Zi certify that In the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation taws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 2k70/ Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> P ,000) IN ISECTION„TO THE ION 97116 OOSTH F COMPENSATION,90R INTEEST,ATTORNEY'S FEF&,AND DAMAGES AS <br /> PRO R <br /> I <br /> (signature ofC-67licensed authorized representative), <br /> hereby authorize(p nt name,___ r/ l 6 ��r <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(t)year and is limited to the work plan dated on the front page of this application. <br /> 5-17-20001 MI __ <br />