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�,. N%4 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 25355 North Highway 99,Acampo,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 they{Business and Professions Code and my license is in full force and effect. <br /> License#: g7't 5 Exp Date: — <br /> Date:.. ont <br /> Cractor.. Gregg Drilling&Testing,Inc <br /> Signature: ` . Tipe: � 1�^S IYt✓tR <br /> Pint Name:.. C. Vl � �VbiV1 <br /> WORKER'S COMPENSATION DECLARATION <br /> 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 /> _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: Grp <br /> Carrier: Policy Number: /t/ � . <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 rovisions o ection 3700 of the <br /> Labor Code, I shall forthwith comply with those provlsi R <br /> Exp.Date: Signature: <br /> Print Name:1 l U1V14 y1 V)lam+ <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,W ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY' FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 9700 OF THE LABOR CODE. <br /> R N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> -.,(signature of C-57 licensed authorized representative), <br /> hereby aut a(print name) to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization Is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> W4Bro?1Mt <br /> EHD YBM 1t15P1 WfL MMITAM <br /> i <br /> I <br /> i <br />