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11/30/2007 02: 48 2093699608 V&W DRILLING PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <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 Division <br /> 3 of the Businm;s and Prof, i s Code and my license is in full force and a ect. <br /> Llcense#: t�(� I E piration Date: <br /> Dats:_ C09"ctor: 'D l r <br /> Signature: c Title: <br /> Panted name; <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 for which this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 37.00 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 number3 are: 1 /� <br /> Carrier. , `� Policy Number. <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 Caiifomia,and agree that tf 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 Dato: Signature: � <br /> Printed Name: '�Vbc v/1 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE Is UNLAWFU AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S1oQ,0o0_), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUT ORIZATION P R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, � �� G� <br /> II (signature o#C-57 licensed authorized representative), <br /> hereby authorize(print name) nc` V-d ►r^�,ty <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand 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 /> 8-29-02!MI <br /> E,HD 29-02001 <br /> 9/30/2002 <br />