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Dec 27 OG 05: 40p RSI Drilling [5317) GGB-2429 p. 2 <br /> 12/27/2006 17:31 FAX 10001 <br /> San Joaquin County Environmental Health Department Unit IV Well PermitApptication Supplement <br /> JOB ADDRESS: B 3 �3 ��r PERMIT SR*: `f �?a <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section.7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License.#: (FO OL CExpiration Date: <br /> Date: la a tractor. S I r� L L f �L <br /> Signature: Title: )' <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally 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 provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 1 <br /> �I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the worts for which This permit is issued. My workers'compensation insurance <br /> carrier and <br /> _policy <br /> {-numbers are: <br /> Carrier. Policy t4umber. <br /> 1 certify that in the performance of the work for which this permit is Issued. I shah 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 w' h t /see provisions. <br /> -4 Expiration Date: t]I v I Signaturek <br /> izi a 1 <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERA IS UNLAWFUL,AND SHALL SUELLECT <br /> AN EMPLOYER TO CRIMINAL_PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($900,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S.FEES,AND DAMAGES A5 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. +` <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION � <br /> i, (signature ofC-67 licensed authorized representative), <br /> l hereby authorize(print name) <br /> I <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 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 /> 8-29-02/MI <br /> ElID 29.02-001 <br /> G/2Z/04 <br />