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10 / 10/ 2008 14 : 47 9253130' - GREGG DRILLING PAGE 02 OrlD <br /> Ctt , i , ld g S , 1PN' Ravence1 Ciei) Ne , c 04 P , <br /> 1J 9 2 2 2 <br /> San Joaquin County Environmental Health Department Unit N Well Permit Application Supplement <br /> JOB ADDRESS : PERMIT 8R#. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Rosiness and Professions Code and my license is in fill force and effect. <br /> License # 4 51e, Expiration Date: J 2a / D <br /> Date: D l7 ntrae r lS 11// lI L� <br /> Signature: �y Title: a� U W1 S n tGWIC(� E <br /> Printed name: yy l r (5 � Pith e <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' compansation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued . <br /> I 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; � �1 r _ <br /> Carrier: l btrf �/ 1 I _ Policy Number: �� o 30) tU _ <br /> I certify that in the performance of the work forwhich this permit is i6oued, I Ghali not employ any pomon in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions Section of the Labor Code. I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: vl✓ Signature: <br /> Printed Name: � h � C IUVI e <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMP40YER TP CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> )T R OTHEl7 THAN CmS7 SIGNING PERMIT APPLICATION <br /> I , (signature ofC•57 licensed authorized representative), <br /> hereby authorize (print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf, I understand this authorization is valid for <br /> one (1 ) year and Is limited to the work plan dated on the front pago of this application- <br /> 8-2941121 MI <br /> EHD 29-02,001 <br />