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t7N CP -1r7 <br /> San Joaquin County Environmental Health Department Unit IV Wail Per it Application S ppplee, ental <br /> JOB ADDRESS: 1717 South Center Street PERMIT SR# 7 �2 <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 /> 1 License #: 465165 Exp Date: 1/31/2010 <br /> Date: I� I Contractor: Gregg Drilling & Testing Inc. <br /> SignaTitle: 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 /> 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 carder and policy numbers are: pu / <br /> Carrier: %%iiovINNfi Policy Number: I� d <br /> v <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: g�t�2tlif, 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 /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 0 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C• 7 licensed authorized representative), <br /> i <br /> hereby authorize(print name) PSC - Paul Anderson ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> i <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 91291021MI <br /> EN029-0111F 7 WELL PEROT APP <br />