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5 — a)r Off 011 <br /> SRI 1 —2-t <br /> VSanrt �Joaquin Environmental Health Department Unit IV Well rmit Application Suppleme <br /> JOB A R E S S 0,-q 610 <br /> Q�A PERMIT SIR 4_4 <br /> _J <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions chi Chapter 9 kcwrimencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> Licensf: ­­_ 9()6_899 Exp Date-. 11/30/11 <br /> Date-- 3/28/11 Contractor: PeneGore Drilling <br /> Signature. Title- CEO <br /> Print Name.. Tuan cu €;n <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations. k1check one) <br /> I have and will maintain a Certificate of consent to self-insure for workers' compensation. as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <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 <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 /> Fxp. Date: 3/28/11 Signature: <br /> Print Name: Tuan Nguyn <br /> WARININGi FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CrVIL FINES UP TO$100,000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES.ANO DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> isignature of C-57 licensed authorized representative). <br /> here W�authorize ;Wlt 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 /> Eho 25,0 11601 <br />