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04i 14i28UL 1;;:b6 5253190:62 - GREGG ORD.1 i:NG PAGE. W <br /> PDI. IA. 200r E:i6AN Ad'v;neiF- 3vIroo«tr#al No. 4i71 r ) <br /> i <br /> San Joaquin County Envirormental Health Department Unit N Well Permit Application Supplement - <br /> JOB ADDRESS; <br /> 4IDbftt1 S}�-8��'t PA PERMIT S1�#: <br /> LICrENSED CONTRACTORS DECLARATIONI( OW <br /> I hereby affirm that I am licensed under the provlslons of Chapter 4(commencing with Section 7000)of DIVISIOn <br /> i 3 of the Business and Professions Code end my license is in full force and effect. <br /> License#: 485165 Expiration Date: 1-31-08 <br /> Date; April .14 2006COntractor. GREGG DRILL1"G & TESTING 'INC. <br /> Signature: Title: OPERATIONS MANACER <br /> 3 <br /> i <br /> Printed name: Mnm9v wA r nFN <br /> WORKERS'COMPENSATION DECLARATION <br /> f <br /> r I hereby affirm under penalty of perjury One of the foliowtng declarations: (CHECK ONE) - <br /> I <br /> XX I have and will maintain a eerkificate of consent to self•Inaure forwvrkers'compensation,as provided for <br /> f ^by Section 3700 of the Labor Code,for the performance of the work for which thin permit is lesued. <br /> h <br /> frrave porf5rameio of <br /> orkfo WhIos 11`14 Pernitia,..n;nnr.,e�i.nr <br /> for fhv potfennerwe of the wedr for whloh thea pemrlt ie leaved: MY wav�nra'wmpw haaoyn B Vow ar iue <br /> comer and policy numbers are'. <br /> Carrion, SEABRIGHT Policy Number: 13131050261 <br /> i <br />{ I certify that In the performance of thewerk forwhich this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Cafdomia,and agree that li'l <br /> should became subject to the workers'compensation provisions of Sa 37G0 of the Labor Code,I shag <br /> fortnwlth comply With those provisons. i <br /> Expiration Date;8-01-06 Signature- <br /> printed Name: . MARY WA DEN <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> foloo,00D.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> i V PROVIDED FOR IN SECTICH 7706 OF THE LABOR CODE. <br /> AUTHORIZATION OR T ER THAN C•57 SIGNING PERMIT APPLICATION <br /> signature oto P IWAsed authorized representative), <br /> L. hereby authorize( nameLAJJ� &hrodV r <br /> to sign this San Joaquin County Walt Permit Application ori my behalf, I understand this authorization is valid for <br /> i one(1)year and is limited in t,a work plan anted on.the ftv.d page of this application. <br /> 3 <br /> j 8.29.021 MI <br /> I, <br /> 622/09 <br /> f <br /> 1 <br />