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San Joaquin County Environmental Health Depsirtrwt Unit IV Well Permit Application Supplement <br />JOB ADDRESS: PERMIT SRlf: <br />LICENSED CONTRACTORS DECLARATION (I—PD) <br />I heroby affirm that I am licensed undorihe provision of Chapter 9 (Commencing with Section 1000) of Division <br />3 of the Business lend ProfeselOn$ COcfe and My license is In f force and OW, <br />License gt 4357 btpiratiCh Date: <br />oath, (/(0 L-)ir 1 -(t <br />Signature: <br />WORKER' COMPENSATION DECLARATION <br />I hereby affirm under penally of pejury one of the following deciaratIone: (CHECK ONE) <br />I have and will maintain e certificate of c,onsent to a elf-ineure for workers' compen <br />j <br />sation as providoci for <br />by Section 3100 of the Labor Code, for the performance of the work for which this parrnitle issued. <br />41 have and will maintain workers oompensation insurance, as i'utred by Section 3700 of the Labor Code, <br />forth, performance of the we* for which-this permit is Essued. My waiters' compensation insUrance <br />carrier and policy numbers arty <br />Carrier; _$ hr tOk--1- <br />I certify that in the performance of the work for which this permit Is issued, Shall not employ any person In <br />any mehrier so este become subject io the woriserre compensation laws Of C Ifornia and agree Enstif I <br />should become subject to the workets' compensation provisions of SePkn,7Q0 of the Labor Code. I ahall <br />forthwith comply with these provisions. <br />kr (A )) <br />WARNING: FAILURE TOSECUR6 vidoaKeke COMPENSATION OYrtAfag IS UNLAWFUL, AND SHALL SUIBJECT <br />AN EMPLOYSR TO CRIMINAL PENALTIES AND CIVIL FINES OP ICON! HUNDRED DIOUSAND DOLLArta <br />($100,000.), IN ADDITION TO THE COST Or COMPENSATION, isrmasr, ArroRNEY'S FEES, ANC) DAMAGES AS <br />PROVIDED FOR iN SECTION Woe OF THE LABOR CODE, <br />UTHORIZA'TION OD= THAN C-57 SIGNING PERMIT APPLICATION <br />(olgrrature of C-87 Ileensed authorized represterdatIvel, <br />horobyreuthorlte •t(ntnrovm) <br />to olun this San Joaquin 00unty Well Permit Application on my behalf. understand this Iluthorizatlan le valid Mr <br />one 0) year and is limited to the work On dated On the front paps of this appriostIon. <br />34e-031 Ml <br />Policy Number: 66 /0 (e,D co i <br />Expiration <br />Datart <br /> <br />Signature: <br />VII ID-1 Printed Name: <br /> <br />01 /Jan, 15. 2007110:44AM53130309 GREGG DRILLING <br />No. 1080 P. 3. 02 <br />66/26/2606 10:42 2694683433 EHD PAGE 22 <br />.°N <br />AVE;U LOH