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05/09/2007 13:38 6503283621 PITCHER DRILLING PAGE 02 <br /> 05/09/2007 WED 13! 09 FAX 293633 SJC BUD 2003/003 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Z 35oo t/.assat R<(- G PERMIT SR#: S o3/5 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Cade and my license is In full force and effect. <br /> License#: 263085 _ _ Expiration Date: 9/40/02 <br /> Date: 5/9/07 Contractor: Pitcher Drilling Co. <br /> Signature: Title:gyrations Manager <br /> Printed name: Terry Shewchuk <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and wilt maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. <br /> R 1 have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Co 9, <br /> for the performance of the work for which this permit Is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 8e0right Policy Number: 681060261 <br /> I certify that in the performance of the work forwhlch 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 California, and agree that if I <br /> should become subject to the workers'Compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Data: 5/9/07 signature: <br /> Printed Name: Terry Shewchuk <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 /> ($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 /> 1, (signature ofC-S7 licensed authorized representative), <br /> hereby authorize(print name) Terry Shewchuk <br /> to sign this San Joaquin County Well Permit Application on my behalf. I 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 /> 7.25.021 MI <br />