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6,11 ? 0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 3:�W Industrial Avenue, Ripon, CA PERMIT SR# <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 California Business and Professions Code and my license is in full force and effect. <br /> License #: 485165 Exp Date: January 31, 2012 <br /> Date: n Contractor: GREGG DRILLING &TESTING INC <br /> Signature: /1 T tie: Operations Manager <br /> Print Name: l�Y�'1�\� n <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> jI hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> i <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: SEABRIGHT INSURANCE COMPANY Policy Number: BB1102345 <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, <br /> and agree that if I should become subject to workers compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: August 1,2011 Signature: <br /> Print Name: <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 3703 OF THE LABOR CODE. <br /> RI�eg7f ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, L (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Binayak Acharya , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization Is valid for one year and Is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMIT APP <br /> EHD 2 101 07M10 <br />