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0'311312008 15:22 925313k , GREGG DRILLING <br />Mar, 18. 2008 3:02,°M1 'Karced G?oEnviro;�,iwt`al <br />PAGE 01 pro <br />N1, 142$ - P. 4 <br />San Joaquin County Environmental Health Department Unit IV Well Parmlt Application Supplement <br />JOBADDRES: - _ 5 CtJ. ll _ .PERMIT SIt#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with section 7000) of Division <br />3 of the Business and Professions Code and rnv license is in full force and effect. <br />I_iCense #; jj 0 ,1Expiraton date: ++ 7,D .10 <br />Date: l 17-40& Contrar; r I t <br />Signature:. _ _ lig- Title: <br />Printed name; <br />WORKER& COMPRNSATION CECLAR'ATION <br />I hereby affirm under penalty of perjury one of the following declarations. (CHECK ONE) <br />_ I have and will mai ntaln a certificate of consent to self -unsure for workers' compensation, as provided for <br />by Section 3700 of the Labor C60% for the per(ormQnce of the work fo r which this permit is issued. <br />ki have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />ToF the perlQrmance of the work forwhich this permit is issued. My workers' compensation insurance <br />C&rrier and policy numbers are: <br />Carrier: c, CSG 'J/1 6 '> — Poticy Number: / 70 (o <br />I certify that in the performance of the work tar which this permit is issued, I shalt not employ any person in <br />any manner so as to become subject to the workers' compensation leers of Califnmia, and agree that if I <br />should become subject to tha workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwfth comply with those provisions. <br />Expiration Date: t / signature; <br />Printed Name - <br />WARNING, FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND allALL SUBJECT <br />AN EMPLOYEE~ To CRIWNAL PENALTIES AND CML FINES UP TO ONE HUNDRW THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INT6R@6 F, ATTORNEr8 FEES, AND DAMAGES As <br />PROVIDED FOR IN SECTION 3708 OF THE I-AUOR CODE. <br />ORIZATJON FOR-91NZR THAN C-57 SIGNING PERMIT APPLICATION <br />of0-51 ficensed authorized representative), <br />hereby authorize (print <br />to sign this San Joaquin County Wall Kermit Application on my behalf. I undaratand this authorization la valid <br />one (1) year and Is limited to the work plan dated on the front page of this application, <br />atmos 79-ft240t <br />6n2/04 <br />