Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL &BORING PERMIT APPLICATION SUPPLEMENTAL <br /> _......... .. <br /> JOB ADDRESS: ............... <br /> PERMIT WP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the California Business and Professions Code and my license Is in full force and effect. <br /> Contractor Name: Gregg Drilling,LLC <br /> License#: _ 1044456 Expiration Date: 9/30/2022 <br /> Signature: Title: Office Manager <br /> Print Name: Mary Walden Date: 12/30/2020 <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 <br /> ❑ provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is Issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> M Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation Insurance carrier and policy numbers are: <br /> Carrier: NFP Policy#:WCO235381-03 Exp. Date: 8/1/2021 <br /> 1 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 law of California, and agree that if I <br /> should become subject to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> for hwlth co I with those provisions. <br /> Signature:_/ <br /> Print Name: Mary Wal n <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION i <br /> I <br /> 1, Mary Walden hereby authorize Shaine Price of Wood PLC <br /> rme nl 1' .N �mM1e11,( e.nR,mhl v Pmlelm.or u e v �y.al j <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.I understand this <br /> authorization is valid for one y/oar and is limited to 1e work plan dated on the front page of this application. <br /> b ynmVlO G [011„ •ulM1erinl IpmUnl.l I <br /> EHD 29.01 8-1.2017 Site Mitigation Well/Boring Permit Application <br />