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i <br /> i <br /> San Joaquin County Environmental Health Department <br /> j WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 30350 S. Tracy Blvd. , Tracy PERMIT SR# <br /> i <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> j I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Califomia Business and Professions Code and my license is in full force and effect. <br /> License#: 485165 Exp Date: <br /> I Date: C Contractor: Gregg Drilling and Testing, Inc. <br /> Signature: ���� Title: C �/G��r���/'��i� ��✓ s <br /> Print Name: C71f✓ �/�//� I <br /> I <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I <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 Cade, 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: ��^ P o I I c y Number: 6�C.l(/�/G(V,//C/ <br /> 1 11 <br /> I 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, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: / / ( I Signature: <br /> Print Name: r--,/"-" 2 /'7cp� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �T RI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> Mansour Sepehr (SOMA E v) <br /> hereby authorize(print name) , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EFw 2"1 OSr09/12 WEU PERMIT APP <br />