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- San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 17720 E. Harney Lane PERMIT VVp #: <br /> LICENSED CONTRACTORS DECLARATION <br /> | hereby affirm that | am licensed under the provisions of Chapter 0 (commencing with Section 7000) of <br /> Division 3of the California Business and Professions Code and nny license iain full force and effect. <br /> Contractor Name: Gregg Drilling <br /> Lioonse #: 1044458 Expiration Date: 9/30/2O2O <br /> S Project <br /> Print Name: Ryan Lea, Gregg Drilling, LLC Dote <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 nf consent tn 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 isissued. <br /> | have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> [� 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 Cnmpop)61icy #: VVCO26749114 Exp. Date 7/1/2020 <br /> | certify that in the performance of the work for which this permit is issued, | shall not employ any person in <br /> any manner an as to become subject to the workers' compensation |ovv of California, and agree that if | <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: / 4 <br /> Print Name: Wyan 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, ATTDRNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 2706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> |, Ryan Lea' Gregg Drilling, LLC ' hereby authorize Andrea Rocha. 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 /> Signature of Griceru�d Authorized Representative <br /> Enozy'n1n7-n1'uozo Site Mitigation Well/Boring Permit Application <br />