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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> PERMIT SR # <br /> JOB ADDRESS: LCD) <br /> LICENSED CONTRACTORS DECLARATION <br /> rovisions of Chapter 9 (commencing with Section 7000) of <br /> I hereby affirm that I am licensed under the p <br /> license is in full force and effect. <br /> Division 3 of the California Business and Professions CodeExpDate • _9L3012011 <br /> License#: 938110 Contractor: Cascade Drillin L.P. <br /> Date: 9/8 2014 <br /> ( Title: General Mana er <br /> Signature: <br /> Print Name: Paul Snelgrove <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> Section 3700 rt ance of the work for which this <br /> the Labor Code, for the perform <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by <br /> permit is issued. as required by Section 3700 of the <br /> performance of the work for which this permit is issued. My workers' <br /> X I have and wifom�ne maintain workers' compensation insurance, <br /> Labor Code, policy numbers are: <br /> compensation insurance carrier and p y Policy Number: 131WD30531 <br /> Carrier: Alaska National Insurance Co. <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 /> ) ��s• <br /> the Labor Code, I shall forthwith comply with those prcq <br /> Exp. Date: 1002 2014 <br /> Signature: ([) <br /> Print Name: Da uI Snelgrove <br /> D SHALL SUBJECT AN <br /> WARNING CRIMFAILURE TO SECURE WORKERS' <br /> PENALTIES AND CIVIL FINES EUPACOVERAGE <br /> $i00,000IN ADDITION NTUOTHE CAEMPLOYER <br /> COST COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> D A. <br /> AUTHORIZATION OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t (signature of C-57 licrosed aathor\zea cepreseoca[lva�, <br /> U to sign this San Joaquin County well & Boring Permit <br /> hereby authorize (print name) <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 /> EH029-01 05/09/12 <br />