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05/24/2006 14:36 7073745677 WOODWARD DRILLING CO PAGE 02/05 <br />03/23/2000 TUE 17:Oi FAX j002/002 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Applica <br />t <br />ion <br />Supplement <br />JOB ADDRESS:S%PERMIT Sit: <br />LICENSED CONTRACTORS DECLARATION (L" Gp) <br />I hereby affirm that I am lioen'2O under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Suefness and Profe;:sione Codd and my Ilcense Is In full force and effect. <br />License #:. _ 7 / O D —7 `i Expirmlon Date: 0 7 <br />Date: L( /a Contractor. 1AJe)0VW )V—n y <br />Signature: ( .��'. CLQ Title: % <br />Printad name: ___Ql&J r—/ A.1 e,-- 4�; UJ y 0 -0 zJri�,Z <br />WORKERS' COMPENSATION DECLARATION <br />I he y affirm under ponatty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certifit;,.de of aonsont to self Insure for workers' compensation, a$ provided for <br />by Section 3700 of the Labor Code, for the performonce of the worts for which this permit Is issued. <br />_ I have and will maintain workers' compensation insurance, as required by Section 3700 of the tabor Code, <br />for the performance of the worts for which this permit Is Issued. My workers' compensMiQn insurance <br />carrier and policy numbers are; <br />Carrier: � ,d�f,�1s� Policy Number: <br />I certify that in the perforrnprice of the work for which this permit is issued, I shall not employ any person in <br />any mannar so as to become subject to the workers' compensation laws of California, and agree that if 1 <br />should beoome subject to the workers' compensation pr+avisions of Section 3700 of the labor Code, I shall <br />forthwith comply with those provisions, <br />Expiration Date: /4)/0(0 Slainaturo, <br />Printed Name. _4._o ,N 4 � ) <br />WARNING. FAILURE To SECURI! WORKERS' COMPENSA71ON COVERAGE 18 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND ClYL FINFB UP TO ONE HUNDRED T'HOU$AND DOLLARS <br />($700,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST. ATTORNEY'S FF.,ES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LASoR 001)[2. <br />AUTHORIZATION IT O HE'R THAN C-67 SIGNING PERMIT APPLICATION <br />I, zl <br />u-��''^Y, (slonature ofC-57 licensed authorized repmuontatAve), <br />hereby authorizo Tint name <br />toRign Ole Sen Joaquin County Well FWMItApplication on my behalf. I undoratand thlo Authortaat;on is valid for <br />one (9) year and Is limltot to iiia work pian dated on the front paQe of thin appllaatlon, <br />8.29-021 MI <br />EHD 29-02401 <br />0z% <br />