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08/07/2007 10: 43 9253130302 GREGG DRILLING PAGE 02 �rU <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 160t Turnpike Road. stockton PERMIT SR#: <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 and Professions Code and my license is in full force and effect. <br /> License#: C Expiration Date: <br /> Date' Contra e ' � r� <br /> Signature: I Titled qjr <br /> Printed name: �r PGCE f <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 forwhich this permit is issued. <br /> 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 /> Carrier:_ 4� Policy Number:17 <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 provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. �> <br /> Expiration Date: U Signature: <br /> Printed Name: 4r1�� � <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,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 37013 OF THE LABOR CODE. <br /> AUTHOfZIN FOR OTHER THAN C,57 SIGNING PERMIT APPLICATION <br /> 1, f (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) Ally c alavita <br /> to sign this San Joaquin County Well Permit Application on my behalf. I undarstand this authorization Is valid for <br /> One(1)year and Is limited to the work plan dated on the front page of this application. <br /> 8-2M21 MI <br /> EHb 29.02.001 <br /> 6/22N4 <br />