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EWELL PERMIT APR 2F4R1 07@0/10 <br /> r <br /> San Joaquin County Environmental Health Department y <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7500 W. Eleventh St. Tracy CA 95304 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 %S2i arc <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License #: � Exp Date: <br /> Date: Z Contractor: Gregg Drilling and Testing, Inc. <br /> i <br /> Signature: Title: ApGlf Q paf y <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION O 3 Zp13 <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 /> CarrierA nra / Policy Number: �/G� <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 S/ l�� 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 3706 OF THE LABOR CODE. <br /> A O TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, ryL (signature of C-57 licensed authorized representative), ' <br /> hereby authorize (print name) Dai Watkins PhD, PE, GE <br /> , 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 /> ❑iD2901 07( v10 - <br /> WELL RERMR MG I <br />