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san joaquln County Environmental Health Services, Unit IV Well Permit AppligtlVytertnnt <br />A-) _Ad <br />JOB ADDRESS: Z1...r0 •-‘00 re 0& AIN-rdir PERMIT SR*: 06076(22 <br />5 RA-terbesk <br />LICENSED CONTRACTORS DECLARATION (150I) <br />I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the BUsirloSS and Professions Code and my license is In full force and effect. <br />License tn, CS? YirS/Cr Expiration Date: ._..e/j3/4 <br />Date: (01,44, Contractur:(40 if.3.1d,.7—&—t—fidstr <br />Signature: Titiatirptivt, /40^ igargreper <br />Printed name: _ay.? <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />X I hire and will maintain a certificate of consent to self-insure for workers coMpensation, as provided for by <br />Section 3700 of the Labor Code, for the perform anoe of the work for which this permit ia Issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />tor the performance of the work for which thiS permit IS issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />CarrierfikPC C Atefrire Polley Number: WI& a1—rbAn30 <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 heCome subject to the workers' compensation laviS Of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 0700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Data: .60/2 C Signature: <br />Printed Name: <br />WARNING: FAILURE 10 SECURE WC/PIKERS' COMPENSATION covenaGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100,001), IN ADDITION TO THE COST OF COMPENSATION, irfrniesT, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />L Cmkr;441,04,- 1344-ar (signature oiC.57 licensed authorised rnorvearnathe), <br />hereby authorize (print name) cgreg`..) rd, AN04,1e. ; <br />to sign this San Joaquin County Well Reath Application cm my bahs/f. I understand this authorization is valid fat <br />one (1) year and Ile limited to the wOrk plan datod on the front page of thus appiication. <br />5-17.2000 / MI <br /> <br />10/02/01 TUE 10:39 FAX 1 916 861 0430 SECOR-SACRAMENTO 2002 <br />Sent By: Gregg Drilling & Testing, Inc.; 925 313 0302; Oct-2-01 10:22; Page 2/2 <br />. wrav btUnt-seRAKENTo 0 0 2