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05119/2005 08: 46 9253130302 GREGG DRILLING PAGE 02 <br /> bb/1U/ltltlU ny:Cir 'ZU-J40d. 456 r I 1 n rL_L-"m ­PAGE­ 02 <br /> san Joaquin County Environmenta9lealth Department unit IV Well Permit AppficatiOn Supplement <br /> JOB ADDRESS' Gam' PERMIT PERMIT SO* <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that 1 am licensed under the provisions of Chaptsr 9(commencing with Section 7000)of Division <br /> 3 of the Business and Pmffe�ssiions Code and my license is in full force and effect. <br /> License* <br /> / <br /> C= O J / Expiration Dene: f� a �' <br /> Date: 5 f� S` onrra C2�G G 'z>,e.c�. <br /> Slgnatum:_Q902� <br /> Title: <br /> Printed name: �� f�� �Lt. <br /> WORKERS' COMPENSATION DEC[-ARATION <br /> I hereby aMrm under penalty Of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of Consent to sell-Insure for workers'compensation,as prided for <br /> by Seetlon 3704 of the Labor Code, for the performance of the work for which this permit is issued. <br /> _I have and vAll 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 /> ca vier and policy numbers are: <br /> r <br /> Carrier. Policy Number: „ <br /> I certiry that in the performance of the work for which this permit Is Issued, I shalt not employ any person In <br /> arty manner so as to become subject to the workers'compensarttorl 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 shat <br /> fortirMth comply with those provisions, <br /> Expiration Date: c_.r S?*"5_Signature: <br /> Printed Name: CP-�� 449 ► i1 <br /> & -J `fz <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.ANo SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINUS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (51 00,000.),IN ADDITION TO TIME COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 5706 Op THE LIBOR CODE. <br /> ALITHOR17WION FQR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> f, (signature afCS7 licensed authorized representative), <br /> hereby eveorize(print name) <br /> to sign this San Joaquin County WeII Permit Application on my behalf, I understand this authorization Is valid for <br /> one(1)year and Is limited to the work pi2n dated on the front page of this application. <br /> 8-29-02 i Ml <br /> END 29-W-001 <br /> R(yW003 <br />