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��• < «�� ��. 1< ��oaiananz GREGG DRILLING ( PAGE 02 <br /> F 1 . <br /> i1 I <br /> San Joaquin County Environmental Health Department Unit IV Well Penult Application Supplement <br /> JOB ADDRESS: 2551 South Airport Way PERMIT SR#: <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 /> l License#: J CJ �I W Expiration Date: IoIy <br /> Date: -1 Cl I��t T2dfl 11-7 , <br /> Signature: ( I rn Title:�7 �7oh C <br /> Printed name:. V I r IS� 2Y 11)r ..1� IAKIer <br /> I <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> —I hsLm and will maintain a certificate of consent to self-insure for workers'cornpensation,ias provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permft 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'compensatkin insurance ' <br /> carrier and policy numbe <br /> rs <br /> ; <br /> are: <br /> Cartier�e, ,�l lt/1! I� - policy Number: I <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 3700 of the Labor Code, I shall t <br /> forthwith comply with those provisions. <br /> Expiration Date: v Signature: <br /> Printed Name. Ch <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT F <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS I <br /> ($900,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> N�FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name)OR- <br /> tosign this San Joaquin County Well Permit Appflcatlon on my behalf. I understand this authorization Is valid for <br /> one(9)year and is limited to the work plan dated on the front page of this application. <br /> 8.29-02 1 MI <br /> r <br /> Erin 29-02401 <br /> norma <br />