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05/02/008 09:46 9253130302 GREGG DRILLING PAGE 02 <br /> Sen Joaquin County Environmental Health Department Unit IV Well Permlt Application Supplemental <br /> JOB ADDRESS: 10 a 2 FC0V1'i7x1C PERMIT SR# <br /> S. 5-fa-k. f20A q 9 E. <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#: Exp Date: ?7 <br /> Date: �✓ V Contractor: t tit I� <br /> Signature: Title: Vl <br /> Print Name. r Vim^ <br /> WORKER'S 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 /> I have and will maintain workers'compensation Insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of tho work for which this permit Is issued. My workers' <br /> compensation insurance carrier and policy numbers are. t 2 <br /> Carrier: r 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 workerscompensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.,Date: / Joe _ Signature: <br /> Print Name' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND CML 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 /> eftf2VOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I� (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) E�1 h����rt —kQG ft .. r to <br /> Sign this San Joaquin county Well Permit Application on my behalf. 1 understand this authorization Is valid <br /> for one year and is limited to the work plan,dated on the front page of this application. <br /> 111291021M1 <br /> END 2901 11!0707 WELL PERMIT AOP' <br />