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EHD 29-01 07/20/10 WELL PERMIT APP I San Joaquin County Environmental Health Department WELL& BORING PERMIT APPLICATION SUPPLEMENTAL 3 I JOB ADDRESS: 800 W Church Street,Stockton,CA 95203 PERMIT SR# 1 LICENSED CONTRACTORS DECLARATION (LCD_) [ 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. i License#: C-57 495-165 Exp Date: / / 11,C s Date: Z// 7 y Contractor: Gregg Drilling Signature: =L= Title: Print Name: WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) i 1 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. 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' compensation insurance carrier and policy numbers are: �7 Carrier;AalrPolicy Number: 6!L0 I 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, I shall forthwith comply with those provisions. Exp. Date: b�.S/�� Signature: -�c— Print Name: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. _ .............................._....._.......................................................................................,.............._.........._......................._.__...._.......................... .. ORI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION _......... . . _ gy �(s-ignature_of C_57 licensedauthorizecLrepresentati�,__ Jiereby authorize(p�Cn�me) to-------------- --- —siar�th_is$an,I_oagmim-County-We1L&-BoringP-ermit- pplication on my-behalf,_Lund.efs_tan- orizion ._......... ..................._.............._._..............._.................._._...........__...._............._._......... ...............__._............__........_..........._..-............................_............._......_._..... .......... _...._ .__....... . .... ... _. is valid for one year and is limited to the work plan dateon the front page of this application. EHD 29-01 07/20/10 WELL PERMIT APP