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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 11530 West Eight Mile Rd . , Stockton , CA 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 #: 485165 Exp Date: 1 /31 /201 .6 <br /> Date: 2/3/2001115 contractor: Gregg Drilling & Testing , Inc <br /> Signature: ( Title: Operations Manager <br /> Print Name: Christopher Pruner <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> X 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: AON Risk Insurance Policy Number: AICW01041403 <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, <br /> and agree that if I should become subject to workers' compensatioq provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pr s <br /> Exp. Date: 8/31 /2015 Signature: <br /> Print Name: Christopher Pruner <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 /> T IZATI F R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, i// { � ; (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) Jeanne Homsey 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 /> EH029-01 05/09/12 WELL PERMIT APP <br />