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i WELL PEFfMIT APP,' EHD 2'f-0107/20/10 San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL 'k JOB ADDRESS: 7500 W. Eleventh St. Tracy CA 95304 PERMIT SR# LICENSED CONTRACTORS DECLARATION (LCD) : I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of .:�ti it 6(I " Division 3 of the Business and Professions Code and my license is in full force and effect. License#: -cyExp Date: Greg g anesDrilling d Testing, Inc. :: Date: 2 Contractor: g g Signature: / ?,opl;Q�� Print Name: /'r WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) X have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued, I I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' ,-_.... . I compensation insurance carrier and policy numbers are: Carrier:09rard, / Policy Number: certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, and ' agree that if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code, ode, I shall forthwith comply with those provisions. Exp. Date: C3 �l� Signature: Print Name: / �C WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO...�_ CRIMINAL PENALTIES AND CIVIL FINES UP TO$900,000, IN ADDITION TO THE COST OF COMPENSATION,INTEREST, „ ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. O TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION i (signature of C-57 licensed authorized representative);_ `1 hereby authorize(print name) Dai Watkins PhD, PE, GE to sign this San Joaquin County Well & Boring Permit Application on my behalf. 1 understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. EHD 29-01 07!20110 ....._ WELL PERW APP