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jSan Joaquin County Environmental Health Department <br /> q WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> i <br /> JOB ADDRESS: 1512 Weiss way, Escalon, CA PERMIT SR# 7I <br /> LICENS-ED-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 California Business and Professions Code and my license is in full force and effect. <br /> License#: 965165 Exp Date: 1/31/19 <br /> Date: �(3 / 3 Contractor: Gregg Drilling and Testing, Inc. <br /> Signature:9 Title: Qi,�Edr'Cyfo/.Li ��D'?t <br /> Print Name:_ C. O- <br /> WORKERS' COMPENSATION DECLARATION <br /> i ; <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 i <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.-Old-Republic-- — Policy umber: 1;CwC-1041302 -- <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, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date; 8/1/19 Signature: � �— <br /> Ch- Print Name: <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, I <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 0—:: (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Ground Zero AnaiXdisign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD28.01 OSIM12 <br /> WELL PERMIT APP <br /> i <br />