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WELL PERMIT APP <br /> EHD 29-01 D7/20/10 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> FJOBDDRESS: _ (� gymPERMIT SR# <br /> CA <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 938110 Exp Date: 9/30/13 <br /> Date. 8/14/2013 Contractor: Cascade Drilling, L.P. <br /> Signature: Q l Title: General Manager <br /> Print Name: Paul Snelgrove <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 <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 /> Carrier: Alaska National Insurance Co. Policy Number: 12JWD30531 <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 Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 10/02/2013 Signature: <br /> Print Name: Paul Snelgrove <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1qb-,S— (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. 1 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 /> WELLPERMIT AFP <br /> EH02M1 07X 10 <br />