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08/08/2007 13:25 2093699608 Ve&W DRILLING PAGE 02 <br /> San Joaquin County Environmental Health De artment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: JoD L� aVLA Y - PERMIT SRO:' <br /> LICENSED CONTRACTORS DECLARATION MD <br /> 1 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 Code and my license Is in full force end a ect_ <br /> License[#/p:I �� U piration Date:+ � D/�U� <br /> Date: �Q C ractor: D vi I 1 i 1 1 �pI,1)c - <br /> Signature: Title: <br /> Printed name: �1l� il'T G - <br /> WORKERS' 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 provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this peril Is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers compensation insurance <br /> carder anddpolicy numberss sib: <br /> Carrier ✓' -"� 1 " n4 Policy Number. <br /> I certify that in the performance of the work for which 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.totti ose ovisions. /l // /g. <br /> F3tpiration Date: Signature:.�il"'l^"Q,/�I <br /> Printed Name Tcbf Y -f F. j 1 <br /> WARNING_FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWF AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE'HUNDREO THOUSAND DOLLARS <br /> (5100,000.),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 /> AUTHORIZATION F9R OT ER THAN C-57 SIGNING PERMIT APPLICATION <br /> (sig tura ofC,07 llcanse"Uth:rt representative), <br /> hereby authorize(print name) <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 /> ed9-021 MI <br /> RID29-02-001 . <br /> 9/302002 <br /> RECEIVED TIME AUG. 8. 1 : 18PM <br />