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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />80111 S. Airport Way, Stockton, CA 95206 JOB ADDRESS: PERMIT SR # <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 California Business and rofessions Code and my license is in full force and effect. <br />906899 1 License #: Exp Date: 1/30/2016 <br />6/23/201.; Date: Contractor: Penecore Drilling <br />Signature: Title: President <br />Than Nguyen Print Name: <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 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 the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br /> Carrier: V\Q4C(J ( U1)\QC\Y-1 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, <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 provisi ns. <br />Exp. Date: S • 6 Signature: <br />Print Name: <br />hereby authorize ( tint name) C ri Dr ban t to sign this San Joaquin County Well & Boring Permit <br />- (signature of C-57 licensed authorized representative), <br />Application on y behalf. I trdeist nd yils authorization is valid for one year and is limited to the work <br />plan dated on the front page 4j4is apHation. <br />1A1 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL 1.113JE rAN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL 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 />AirTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />Er-0 25 01 05:09.' 1 <br />;-FPMI"