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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 17720 E. Harney Lane pEFlNq|T VVp #� <br /> LICENSED CONTRACTORS <br /> | hereby affirm that | am licensed under the provisions of Chapter 0 (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: Gn*gg Drilling <br /> License#: 1044456 Expiration Date: A/3O/2020 <br /> � <br /> Signature: Title: Project Manager <br /> Print Name: Ryan Lea [)ate:3/24/202O <br /> WORKERS' COMPENSATION DECLARATION <br /> | hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> | 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 /> | have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> 0O 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 Zurich American Insurance Compap)61ioy #: VVCO26740114 Exp. Date: 7/1/2026 <br /> | certify that in the performance of the work for which this permit in issued, | 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 /> forthwith nnnnp|y with those provisions. <br /> Signature: <br /> Print Name: Ryan Lea, Gregg Drilling, LLC <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 |N SECTION 37OGOF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i Ryon Lea' Gregg Drilling, LLC ' hereby authorize Andrea Rooha. San Joaquin County <br /> Name of C-57 Licensed Authorized Representative Print Name of Authorized Agent <br /> to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br /> Signatu C-57 Licensed Authorized Representative <br /> s*oceo1o7-o1'2ozo Site Mitigation Well/Boring Permit Application <br />