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Nov 17 06 10: 49a Miell Drilling 70704-9049 10• 2�r� <br /> Nov. 17. 2006 11 :39AM onced GeoEnvironmental No. 6823 P. 2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: z-2 1i T6 I-cu& GctV St PERMIT SRM: <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby athrrn that I am licensed under the provisions of Chapter 9(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#: c--57-P- 6 7 Z6 ( 7 Expiration Date: 6, 3 O Z O 7 <br /> II�l70G Contractor. /L4 <br /> Date: �p <br /> Signature: Title: y r <br /> Printed name: � L G G� <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 cerhffcate of consent to self-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance o`the work for which this permit is issued. <br /> I have and will 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 /> carrier and policy numbers are: <br /> - Fri 6 NS GO ,- Pofic Number. 4b - 007562 -01 - y 2 <br /> Carrier: u £-tj - I Y <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 California,and agree 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 /> 7 � <br /> Expiration Date: G b 1 Signature: <br /> Printed Name: �y� �'l✓�(1�"' <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 /> iADDITION <br /> IN SECTION 17 B OOF T EF COMPENSATION,INTEREST.ATTORNEY'S FEES.AND DAMAGES AS <br /> PROVIDED OR <br /> AUTHORIZATION FOR OTHt:R THAN C-57 SIGNING PERMIT APPLICATION <br /> l �J— G -r_ <br /> (signature ofC-57licensed authorized representative), <br /> hereby authorize(phut name) f J( <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application- <br /> 8-29-02!MI <br /> EHD 2902-001 <br /> [n.,m� <br />