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05/22/200a 15:46 92 GREGG DRILLING" PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB Ilk) <br /> ADDRESS: �,�-�'s� - ; V <br /> ` mrk-0--� PERMIT SRA SAZi �I� <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 Business and Professions Code and my license is in full force and effect. <br /> License#: 48 1(D� Exp Dattee: I,'31 1P 0 <br /> Date: 2 Contractor: Qt�wi�� TV iI I I L14 ` /�hY� G <br /> Signature: Title: � a-hohS NkltY1�ZGfe*9- <br /> '' II + <br /> Print Name:M �( l t.lafjn <br /> WORKER'S 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'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 /> 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 carrierand policy numbers are: <br /> Carrier; Ior( lir <br /> rrPolicy Number: 65/07 d2Ga <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, and <br /> agree that if I should become subject to workers'compensation provisic Section 3700 of the <br /> Labor Cade, I shall forthwith comply with those pro n <br /> Exp. Date: o t ( 1 Signature: t ' _ <br /> 'f �Print Name: Mit <br /> I. <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO S1D0.D00,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> AfJ O �I fOR OTHER THAN C-37 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 Ncensed authorized representative), <br /> hereby author z (print name} CAC1TnNN&lNE�Nh to <br /> sign this San Joaquin county Well Permit Application on my behalf. i understand this authorization is valid <br /> for one year and is limited to the work plan dated On the front page of this application. <br /> ussroxnAl <br /> ENO 1B4� �i�SV1 <br /> WELL PEPM1 APP <br />