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t <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 16470 Cambridge Dr.,Lathrop, CA 95330 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 <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 485165 Exp Date: January 16, 2016 <br /> I Date: May 2, 2014) Contractor: Gregg Drilling & Testing, Inc. <br /> Signature: �T/ Title: <br /> Operations Manager <br /> Print Name: Christopher Pruner <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> X 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 /> X I 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:ARI Policy Number: ARCW01041101 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:August 31 , 2014 Signature: — , <br /> Print Name: Christopher Pruner <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> t! ION FOR OTHER THAN C-57 SIGNING PERIRIT APPLICATION <br /> I, f (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Tw-n vis-_ Povv sfv ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 understand this authorization is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> 8n91021M1 <br /> El N01 11W7 WELL PERMIT APP <br />