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08/08/2007 13:25 2093699608 V&W DRILLING PAGE 02 <br /> � y <br /> San Joaquin County Environment�all-, <br /> Health De rtPermit ment Unit IV Well Peit Application Supplement <br /> JOB ADDRESS:��� @f\ UU Ty' PERMIT SRO: o u 5- <br /> LICENSED CONTRACTOR DECLARATION LCD <br /> I 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 and eject <br /> - }^�) <br /> License#: ��U piration Date: - Q v <br /> Date: ? C rector. D vl I nr) <br /> Signature:( <br /> Signature: C� ,.'/,, ,�/ `/ Title: <br /> Printed name: 1�D1��� li - CX"i tom( <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 permit 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 /> carrier and policy numbers are: <br /> /� <br /> Carrier. 6f-a")-f- Find <br /> Policy Number. l_"yV/ ',JWV <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'd I <br /> should become subject to theiworkers' compensation provisions of Section 3700 of the labor Code. I shall <br /> forthwith comply IVose ovlsions. /iExpiration Date: Signature: / 1^Qf <br /> Printed Name: Wb ' j Z 1 <br /> WARNING, FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFU AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),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 <br /> FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (slg tura ofC-57 licansedauthorlod representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for - <br /> one(11 year And is limited to the work plan dated on the front page of this application. <br /> 0.29-02/MI <br /> EW 2"2-001 <br /> 9/302102 <br /> RECEIVED TIME AUG, 8. 1 : 18PM <br />