Laserfiche WebLink
EHD 29-01 07120110 WELL PEFE�fT Af�P <br /> Sr/ <br /> i <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> _.z <br /> JOB ADDRESS: 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#: �� 7 �T/,r Exp Date: <br /> Date: Z contractor: Gregg Drilling and Testing, Inc. <br /> Signature: Title: '"�l�,<,::: 0 pBf <br /> r _ i <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjuryone 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:firar6l / Policy Number: <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 <br /> Code, I shall forthwith comply with those provisions. <br /> Exp. Date: O Z/=i! Signature: � � <br /> Print Name: /' <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 37o6 OF THE LABOR CODE. <br /> O TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i, (signature of C-57 licensed authorized representative)','. ' <br /> hereby authorize(print name) Dai Watkins PhD, PE, GE ,to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD29-oi o7rmio <br /> WELL PERM[T-APP <br />