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JHN 11 2002 10: 36 GREGG, DRILLING 9253130302. <br /> ... �� �, n,:i I��uiV4V'SICJ p.3 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 24 B �� <br /> Stockton, CA PERMIT SRS: <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> i her h affirm that i am licensed under the pretisions of Chapter 9(connrnenung with Section 7ppp)of f3ivlslon <br /> 3 of the BUSiness and Professions Code and my license is in full force and effect. <br /> License#: 485165 <br /> J=xpiration Date.. 1 /31 /02 <br /> Date 1 11 Coritractoq Gre Ig & Test n <br /> Inc <br /> Signature <br /> Title:0 era.tians Man er <br /> Printed na,rne• Chri <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (CHECK ALL THAT APPLY) <br /> I have and W11 inalntalna certif'lcatb Of consent to self-Insure for workers`compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for whir.{, this permit is issued. � <br /> X i have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the pertormance of the work for which this permit is rlssued, My workers'compensation Insurance <br /> carrier and pnl,cy numbers are: <br /> Carrier. Mack & Park r Policy(Number: <br /> i <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 Californie, a ree that If I <br /> r should become subject to the workers'cempensafion p ons of Section 3700 oft Labor Code, I shall <br /> forthwith comply*th those provisions. <br /> Daae: �' <br /> ��.��-^Signature• <br /> Printed Name: <br /> l WARNING:FAILURE TO SECURE WORKERS'COMIPENSATIDN COVERAGE 15 UNLAWFUL,AND SHALL SU13JECT i <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF CO SATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR IN SECTION 3nS OF THE LA OR ODE. <br /> L' ' tum afC-3)gcensed authorizea representative), <br /> hereby authorize(print name) Chri her P un <br /> to sigh ihia San Joaquin County well Permit Application on my behalf, II understand this authorization I!valid for <br /> one t�)your and is limbed to the work plan dated on the front pAge of this application, <br /> ,5-17-20001 Ml <br />