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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 16888 McKinley Road PERMIT WP #: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: Gregg Drilling,Inc. <br /> License#: 485165 _ Expiration Date 01/31/2020 <br /> Signature: z _ Title: 'Operations Manager <br /> Print Name: (f*k,/.Z potU/I g/' Date: <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 <br /> E 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: Attached Policy#: ___ Exp. Date: <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 law of California, and agree that if I <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> torthwlth cut tl tly with those provisions <br /> Signature. f <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, CkfA-1 pewe? r , hereby authorize Garrett Thornton <br /> NI.in ItCAIl 11�I,r,nriuirrttM Nn�xe+on.�•�:- -- - Pnnl N­,tAulho 1J AgInt <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf. i understand this <br /> authorization is valid for one year and is limi i -work pla ated on the front page of this application. <br /> t,pn.gen nl CSi lrtMrM 11wMn,ItM Nepr.amwlr. <br /> EHD 29-01 8.1-2017 Site Mitigation Well/Boring Permit Application <br />