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v / <br /> 100" 0-" <br /> San Joaquin Count Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: Nw co er / Intersection of PERMIT SR# o? & ^ - <br /> CorralHollow & Grant Line Roads <br /> Tracy, California <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#: 9383-10 Exp Date: 9/30/11 <br /> Date: March 26, 2 010 Contractor: Cascade Drilling, L.P. <br /> Signature: ;:zx cs `- Title: Operations Manager <br /> Print Name: Paul Snelgrove <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 /> X 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 carrier and policy numbers are: <br /> Carrier: American Zurich Co. policy Number: WC3999959-01 <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 provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 10/2/2010 Signature: <br /> Print Name: Paul Snelgrove <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) Allen Just of ARCADIS U.S. , Inc. ,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 /> 9/29/02/MI <br /> WELL PERMIT APP <br /> EHD 29-01 11/5/07 <br />