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12/05/2007 08:45 9253102 GREGG DRILLING PAGE 01 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> X20 �� PERMIT SR#: <br /> JOB ADDRESS: L( C� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 3 e the Business and professions under the pro�Code and my license s Chapter <br /> full force and effect.with Section 7000) of Division <br /> Ak Q Expiration Date: <br /> License#: <br /> Date: Q Contractor: <br /> ��r---- Title: <br /> signature: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ONE) <br /> I have and will maintain a by Section 3700 of he LabortC de, for the ificate of sperfoent oself-Insure <br /> of the work for which th for workers, snpe m t is i sued.ed for <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Lobos Code. <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> �k� Policy Number. <br /> Carrier: -_� <br /> ch <br /> it is issued, I shall nOt employ any OeWn <br /> anymanner lso as to became subject toce of the �he rk workelrs compensation laws of California, and agree that i I In <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Gude, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: rte.-LtZIL Signature: <br /> Printed Name: <br /> 'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> WARNING: FAILURE TO SECURE WORKERS <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> heretry author (printname) <br /> i to sign this San Joaquin County Well Permit Application on my, behalf. understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> I <br /> 6.29.02/MI <br /> EHU ZJ•OZ-fit <br />