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�: 9253130302 GREGG DRILLING PAGE 01.U,,D <br />` D 3'02 1 N1 .dvanced G4oEnvironment)l No,'41,8 P, 4 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRES: �5 �U /l D`'t / ���/. PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I arr licensed undor the provlslons of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Cade and my licenso is in full force and effect. <br />Lioense #;"-, I Expiration Date: I 10 <br />Dote: ISI <br />11 og Contra r: <br />Signature: I Title:01S' ? <br />Printed name: !` (� jcr 0-7) <br />WORKERS' COMPENSATION DECLARATION <br />I heroby affiml 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 3700 of -th8 Labor Code; <br />or the performance of the work for which this permit is issued. My workers' compensation insurance <br />career and policy number <br />s are: <br />Carrier: SSC rI POIIcy Number: 7 ( % <br />certify that in the performance of the work for which this permit is issued, I shall not empioy any pertdn M <br />any manner so as to become ®object to the workers' compensation lews of Calffomia, and agree that if I <br />should became subject tc the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions, <br />Expiration Date; /Signature; <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDR60 THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTFREST, .ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE I-AI30R CODE. <br />AUT OW R1ArdON FO <br />RTHER THAN C-67 SIDING PERMIT APPLICATION <br />h / <br />of0-57 licensed authorized fupresentatlya), <br />hereby authorize (print <br />to sign this San Joaquin County WAIT hermit Application on my behalf. I understand this authorization Is valid <br />ane (1) ytor and Is limited to the work pian dated on the front page of this application: <br />FM 24.02�00T. <br />6122104 <br />