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Jun 20 05 04: 15p Grp Drilling ,920302 P• 1 <br /> San Joaquin County vironmental Health <br /> Deepa Iment Unit V Well Permit Application PPI?ment <br /> JOB ADDRESS: �� '�� W'sv " -" PERMIT SR#: y)GG <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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#: <br /> L4 0 � Expiration Date: I I D <br /> Q � I� O (./' <br /> Date: Co Contractor: ( lrfi /f <br /> Signature: // Title: <br /> Printed name: "14 WQ W <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 /> 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 /> carder and policy numbers are: <br /> Cartier: 5'-ea brt Q Policy Number: <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'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: .-.�I.1a�gnature: ----- <br /> Printed Name: —__- - -- ---- ------------ <br /> ON <br /> GE IS UNLAWFUL,AND SHALL <br /> AN EMIPLOYERLURE TO TO CRIMINECURE WORKERS'AL PENALTIES AND CIVIL EFINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> COST <br /> T ELAOR NSA nON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> F <br /> PROVIDED FOR N SECTION 3706 OF <br /> AUTHORIZATION FOR OTHPR THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 I I Y l 0 (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I u derstand this authorization is valid for <br /> one(t)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> EHD 29-02-001 <br /> 6/2L04 <br />