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9253 1 3030 2 <br />215 (;#x <br />-7 <br />contractor, <br />Qo <br />Expiration Date: j ) ( 0 License #: <br />Date 10 <br />Signature: <br />Printed name: <br />La <br />Oct 05 05 11:08a GREGG DRILLING <br />CP-1- / <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 3 /Vag /'4 -Cr-PERMIT SR*: 00043ft <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license Is In full force and effect <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm 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 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: <br />Carrier. Si' hi <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 700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: JC:431Acitignature: <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 HUNDRED THOUSAND DOLLARS <br />($100,000.), IN AMMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />LA )01 d_ (signature alC-57 licensed authorized representative), <br />hereby authorize (print name) <br />to sign this San Joaquin County Well Permit Application on my half. I understand this authorization s valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />3-29-02 I MI <br />END 29-02.001 <br />9/30/2003 <br />Policy Number: 66i DS 01(0