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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 25355 North Highway 99,Acampo,CA PERMIT SR# <br /> �i <br /> LICENSED CONTRACTORS DECLARATION (LCD)' 4 <br /> I hereby affirm that I am licensed under the provisions of Chapter 3 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect <br /> License#: 1 g�7 0 Exp Date: f �� 1 k L <br /> Date: ��19a Contractor: Gregg Drilling&Testing,Inc <br /> k Signature: Title: Q � tiI�S <br /> Print Name: CUIy\ �►1 WN�1 <br /> WORKER'S COMPENSATION DECLARATION <br /> I 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 r <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' 4` <br /> compensation Insurance carrier and policy numbers are: <br /> Carrier: Policy Number: r.)Il9l�2yJ� <br /> E 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 provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with thosep i ' <br /> 1 , <br /> Exp. Date:_ 00'117-a1(Q Signatu ` . , � � <br /> Print Name: C�d15"�U7�1� �VIAd1 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$700,000,INIADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.6;M&j -- <br /> { <br /> i O R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I I, (signature of C-67 licensed authorized representative), <br /> hereby authorize(print name) to <br /> I sign this San Joaquin county Well Permit Application on my behalf. 1 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 /> i` <br /> 1 arzaroz�rrl <br /> EHD] j li517 WEU PERMIT APP <br /> I <br />