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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 8010 SOUTH AIRPORT WAY, STOCKTON PERMIT SR#: <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: CASCADE DRILLING L P <br /> License#: 938110 Expiration Date: 9/30/2017 <br /> ogroiry°ig°°°oy raxme°na°q <br /> :20V Regional Director <br /> Signature: °"�"��""°'°"��m <br /> oma:mte.ron is:2c:zyoma Title: g <br /> Print Name: Ralph McGahey Date:10/17/2016 <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 /> 13 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 /> 0 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: ZURICH AMERICAN INSURANCE COMPANY policy #: WC0137344 Exp. Date: 11/01/2016 <br /> 1 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 /> forthwith comply with those provisions. <br /> Digitally signed by cascadedrilling <br /> DN:-US,st--,i=,o=Cascade Drilling,c-cascadeddlling,email=ca@emailsignature.com <br /> Signature: Date:2016.10.17 15:21:00-07'00' <br /> Print Name: Ralph McGahey <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, Ralph McGahey , hereby authorize Scott PolSton <br /> Name of C37 Licensed Authorized Representative Print Name of Authorized Agent <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 limited to the work plan dated on the front page of this application. <br /> ����/i °gray sN^ea ev racra°eanir9 °ea <br /> amen=ra�m°eiwmew064 <br /> Gate. 71521'.OB-0]110' <br /> Signature of C-57 Licensed Authorized Representative <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />