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s <br /> �q EHD 2"i 07=110 <br /> WELL PEOMif APP,° <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <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 :stair azf ' <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: Exp Date: <br /> GreggDrilling and Testing, Inc. .; <br /> Date: Z Contractor: 99 9 9� <br /> Signature: ZTitle: . OX _471e 04 <br /> Print Name: l �G1/!ol�' <br /> WORKERS' COMPENSATION DECLARATION <br /> l I hereby affirm under penalty of perjury one of the following declarations: (check one) r . <br /> } X <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 /> XI 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: A,^0rd / 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: Signature: �•-�—� <br /> Print Name: /cr <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 /> 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 /> E HD 29-01 07r"O <br /> - WELL PERMPT•APP <br /> .. I <br />