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08/15/2008 15:27 925313 ` GREGG DRILLING PAGE 02 <br /> 3 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: <br /> 15 3(o N— PERMIT SR#: 0 S S !S <br /> LICENSED CONTRACTORS 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 <br /> and Professions Code and my license is in full force and effect. <br /> License#: L&1 Expiration Date: I <br /> Date: f ac e UY)� I �? �7~ h 4- - <br /> Signature: `` Title: �5E <br /> Printed name: <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 �olliiccy�numberrss are. <br /> Carrier. 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'compensa' I of Cali and agree that if I <br /> should become subject to the workers' compensa ion the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: DI til Signature: V7J <br /> Printed Name: HP — <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINFS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF CO PENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOROINSETIO 06 OF TH B R CODE. <br /> HER THAN C-57 SIGNING PERMIT APPLICATION <br /> ( /" (signature ofC-67 licensed authorized representative), <br /> hereby au odze(printname) MoS VIM <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one(t)year and In limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> EHD 29-02.001 <br /> 6/22/04 <br />