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zoos � <br /> San Joaquin ounty Environmental Health Department unit IV Well rmit Application Supplement <br /> JOB ADRC 'r*I`r lYr u�� Crt- PERMIT SIR <br /> LICENSED CONTRACTORS DECLARATION (LCD ) <br /> I hereby i3fmm that I and l: r`.Sca under thEc provis.ons Of Chapter 0(commencing witht Se--ti--n 7000)of <br /> Division, 3 of the Business and Professions Code and my license Is in full force and effect. <br /> t"icense= _ 94 899 . _. Fxp Date- __11_/30/1 1 ........—__ <br /> Date: 3/28/11 Contractor: PeneC©re Drilling <br /> 9 <br /> 1 <br /> Signature: Tide: CECT <br /> Print Nafne Tuan get en <br /> l WORKER'S COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one of the following declarations. (check one) <br /> l I have and will maintain a certificate of consent to self-4nsure for workers' compensation. as <br /> E provided for by section 3700 of the labor Code. for the performance of the work for which this <br /> E <br /> �/ permit is issued <br /> �` I have and;tiill maintain .vorkers'compensation insurance, as required b Section 3700 of the <br /> R q y . <br /> Labor Code: for the performance of the work for which this permit is issued My war`Rers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier State Fund Policy Number: 059-0000439-10 <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any j <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 those provisions. <br /> Exp. Date: 3/28/11 Signature: <br /> Print Name: Tuan N u n <br /> WARNING:FAILURE TO SECURE WORKERS'COLIPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> 3 <br /> CR19.SihtAL PENALTIES AND CIVIL FINES UP TO 5370,40.IN ADDITION TO T?iE COST OF COb4PENSATtON.IEdTEREST, <br /> ATTORNEYS FEES.AND DAJAAGES AS PROVIDED FOR IN SECTION 3745 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, f^ wc' (signature of C-57 licensed authorized representative), <br /> hereb authorize nt name) Heidi Dietrich to <br /> sign this San Joaquin county Well Permit Application on my behalf. I 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 />