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06/30/2005 14:49 9253130302 GREGG DRILLING PAGE 02 <br /> Jun 30 05 02;21p Pater Weill: 1 938-1610 p.2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:'�,U k7 4,,r`L MC4,z > RERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I em licensed underthe provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license Is in full forge and pffelcl. <br /> License (� Expiration Date: 1/31 p <br /> Date: C D9 tmt r: C I , <br /> Signature: Title: OR,, 4N\y 4t1&!kt'" <br /> Printed name:' <br /> ki <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 pnuvided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this pem7it is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Cade. <br /> for the performance of the work for which this permit Is issued. My workers'compensation insurance <br /> carrier and policy numbers are: --yy <br /> Carrier. t 12� `Lq�► Policy Number: oaP( . <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 vi ions CC, on 3700 of the Labor Code, I shall <br /> forthwith comply ith those provisions_ <br /> Expiration Dote: I CICS Signature: V <br /> Printed tilers: YUer I 1 11 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND$HALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S100,000.).IN ADDITION 70 THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUT 0 10R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> PA <br /> I. (signature oIC-67licensed outhorized representativo), <br /> hereby authorize(print name) <br /> to sign this San Joaquln County Well Permit Appllaatlon on my behalf. I understand this authorization Is valid for <br /> one(1)yearend Is limited to the work plan dated on the front page of thle application. <br /> 8-29-02 f MI <br /> EMD:9.02.071 <br /> 6/22/C4 <br />