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10/1j/2006 14:56 9253130302 _ GREGG DRILLING PAGE 02 <br /> act 11 2005 2: 14PM Rarm Environmental , Ino 19161 New- 1796 P-2 <br /> San Joaquin County Enviranmental Health Deportment Unit fV Well Permit AppNeallort Suppfamert <br /> JOB ADDRESS: 'L21 P wP 0115 K 4kyF.4 $TochTofk PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under thQ provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Ovalness and ProNsslons]Code and my iicense is In furl force and effect. <br /> License* ! r Expiration Date: <br /> Dale: 10—d— Conti r: 11f 1 i <br /> Signature: <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the rullaMng declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to gaff-Ineure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the perlormence of the work for which this perrhll Is issued, <br /> have and will maintain workers'compensatlon insurance, as requW by Section 9700 of the Labor Code, <br /> for the performance of the work for which this permit Is Issued. My wofkers'comppnsatlon insurance <br /> carrier and policy numbers arv.. <br /> CwTiar I Policy Humber: 060 I <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of CelHorinia, and agrea that if I <br /> should become subject to the workers'compensation provisions of S to 700 of the Labor Code, I shall <br /> forthwith compiy Ith those provisions. <br /> Expinulon Deft;F ,Jl o 7 Slgnatum:_ _ - -------------�_„__Printed Name: <br /> Name• ---------- <br /> WARNING,FAILURE TO SECURE WORKERS'COMPEN TION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PE ALT1ES AND CIVII,FINES UP To ONE HUNDRED TMOUSAND DOLLAR$ <br /> (:100,000,)6 IN ADD1'1<tON TO THE COST OF COMPENSATION,INTEREST,ATrORNEY'a FEES,AND DAMAQ96 As <br /> PROVIDED FOR IN SEICTION 3706 OF THE LABOR CODE. <br /> AUT RATION FOR THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, fslgnature afC4 7 licensed authoAhed roprevordativsi, <br /> horsby suthorfre(prl me) T05 E P H art A M 4 0•IF _ <br /> , <br /> to sign thle San Joaquin County Well Perrnit Application an my behalf. 1 undomtond this authorization Is valid for <br /> one(1)year and Is Ilmhod to rhe worn pian dated on the front pegs of this splAcwtion, <br /> 9-211-021 Mf <br /> CHD 19-02-001 <br /> 6122104 <br />