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EHD 28.01 07/20!10 <br /> WELL PERMIT APP <br /> FBusiness <br /> an Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> : 502E Grant Line Road., Tracy, CA PERMIT SR # <br /> ICENSED CONTRACTORS DECLARATION (LCD) <br /> at I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> usiness and Professions Code and my license is in full force and effect. <br /> 99 Exp Date: 11/30/2013 <br /> Date: Li L-1 Z Contractor: Penecore Drilling <br /> Signature: Title:_( 1 Q <br /> Print 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 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: S11 (k_ Policy Number: UC00l31 - ZOt 1 <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: 17— Signature: c/ <br /> Print Name:_'tUG 1-1 <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 /> AUTHORI WION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> / (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Parsons <br /> to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 1&01 07/70/10 <br /> NE-L PERMIT APP <br />