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UZI Z212uub lb: 12 'J2t:�13O3O2 GREGG DRILLING PAGE e2 <br /> San Joaquin County Environmental Health Department Unit IV Well Pormlt Application Supplement <br /> JOB ADDRESS: 1444 south Lincoln street PERMIT SR#: S 35"t <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 5 (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#: I `+� Expiration Date: I 3/ U 10 <br /> Date: r` Co (1\ ��-t-1► �!�- <br /> Signature: Title: <br /> aQ . <br /> Printed name: r <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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 /> /1 I have and Will maintain workers' compensation fnsurance, as required by Section 3700 of the Labor Code, <br /> r" for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: `� f <br /> Cartier. Policy Number: ?� f 7C I <br /> 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 agn�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: `� Signature: ` F <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ZAT FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (az (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Appricatlon on my behalf. 1 understand this authorization Is valid for <br /> one(1)year and in limited to the work plan dated on the front page of this application. <br /> 8-29-02 I MI <br /> EHD 29-02-001 <br /> �n�ma <br />