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NF1 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 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 <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> i <br /> License #: C-57 license 888763 E p Date: 12/31/2009 <br /> Date: April 13 , 2009 Contractor: estern Resource Management <br /> ' o.aoMsgMebv.n.Mwilh <br /> Signature. <br /> Title: Senior Geologist <br /> Print Name: Thomas E. Ballard <br /> WORKER'S COMPENSATION DECLARATION <br /> i <br /> I hereby affirm under penalty of perjury one of the following c eclarations: (check one) <br /> 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, forte performance of the work for which this i <br /> permit is issued. <br /> x 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 re: <br /> State Compensation <br /> Carrier: Insurance Fund _ Policy Number: 541-417-2009 <br /> I <br /> i <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, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the i <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: <br /> I <br /> March 1, 2010 Signature: <br /> Print Name: Tliomas E . Ballard <br /> i <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 ADDI ION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTI DN 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 IGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) o 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 /> 1 <br /> 81 wwwI <br /> EHE 29-01 1115107 WELL PERMIT APP <br />