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05/15/2002 15:42 7078234258 WEEKS DRILLING PAGE 02 <br />05/15/2002 14:28 2094_.,433 FIFTH FLOOR PAGE 01 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: PERMIT SR#: <br />crckcy <br />LICENSED CONTRACTORS DECLARATIONL( CDS <br />I hereby affirm that'I am licensed under the provisions of Chaptor 9 (Commencing with Section 7000) of Dlvislon <br />3 of the Business and Prooffessl/ons Code and my license is in full fora' and effect., <br />License #: LS7- 1 ! 711 1 Expiration bate: /D2 - <br />d Porno Cb,. <br />Date: 511-7102, Contrack r 1 n <br />L-1 `� <br />Signature: Tltla, _ ri jj I M 6�Q. 4 1X - Lw <br />Printed riarne' n2�d <br />WORKERS' COMPENSATION DI�CLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />y I have and will maintain a certificate of content to self -insure for workers' compensation, as provided for by <br />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 the Labor Code, <br />for the performance of the work for which this permit is Issued. My workers' compensation insurance <br />carrier and policy numbers are: / ,' l r� 1 <br />Carrier: -(r-) r. E tind t jrnPolicy Number: (_U�t 1 ' (� I <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 California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 37 17 of the Labor Code, I shall <br />forthwith comply with those provisions. 1 <br />Date: 5/1 6-2 Signature: U <br />Printed Name: DonD I n Gr <br />WARNING: FAILURE TO SECURE. WORKERS" COMPENSATION GOVERACE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO T -H ST OF COMPENSATION, IN'T'EREST, AiTORNErS FEES, AND DAMAGES A5 <br />PROVIDED FOR IN SECTION 5706 F THE LABOR CODE, <br />1, (signature ofC-57 licensed atithorizOd representative), <br />rn r r I a.r <br />hereby authorize (print <br />to sign this San Joaquin County Well Permit Application on my behalf. I uriderswd this authorization is valid for <br />one (1) year and Is limited to the work plan dated on the front page of this sppRcation. <br />5-97.2000 <br />