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06/07/2607 10:43 9253130302 GREGG DRILLINGPAGE 92 DAU i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: = �UPERMIT SIS#: 1)052-� z7.. <br /> LICENSE© CONTRACTORS DECLARATIONL( CD) <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 /> License#:� �� 4 <br /> Expiration Dat{e;� / <br /> Date: Contra 4 r! <br /> Signature: Trtiei � af!/or7�r <br /> n <br /> Printed name: <br /> WORKERS'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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> Il <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'Compensation insurance <br /> Carrier and policy numbers are: <br /> r <br /> Carrier: Policy Number: r , <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'oompensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: U 0 Signature: <br /> Printed Name:J <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALT_SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THt;COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHO I N FOR OT ER THAN C47 SIGNING PERMIT APPLICATION <br /> I' (Signature ofC-57 licensed authorized rapi'seontative), <br /> hereby authorize(print name) — c in <br /> to sign this San Joaquin County Well Permit Application an my bohalf. I understand this authorization Is valid for <br /> on@(1)year and Is limited to the work plan dated on the front page of this application. <br /> 8-29 021 MI <br /> ERn 29-02-Wt <br /> 6122104 <br />