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?V)10 A,,q�4 <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 8010 SOUTH AIRPORT WAY, STOCKTON PERMIT SR #: <br />LICENSED CONTRACTORS DECLARATION <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 />Contractor Name: CASCADE DRILLING L P <br />License #: 938110 <br />Signature <br />Expiration Date: 9/30/2017 <br />ogroiry a�gnaa oy raxmeanaoq <br />Title: Regional Director <br />malkr�amalYlgnaNre.com <br />Gala: 2018.t0.t r 15:20'Ty L]YIP <br />Print Name: Ralph McGahey Date: 10/17/2016 <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 />13 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 />0 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: ZURICH AMERICAN INSURANCE COMPANY policy #: WC0137344 Exp. Date: 11/01/2016 <br />1 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 law of California, and agree that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Digitally signed by cascadedrilling <br />DN: -US, st--, i=, o=Cascade Drilling, c-cascadeddlling, email=ca@emailsignature.com <br />Signature: Date: 2016.10.17 15:21:00 -07'00' <br />Print Name: Ralph McGahey <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, Ralph McGahey , hereby authorize Scott PolSton <br />Name of C37 Licensed Authorized Representative Print Name of Authorized Agent <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br />0gtary 106 av 521 06 nNrg aea <br />ore ��s. n=. i=.. o=ca,mca onni�. �n=ava rcimq, <br />emal=ra�amaiwv�ama.wm <br />Gate. 20te.t0.tl t52t'.OB-0]110' <br />Signature of C-57 Licensed Authorized Representative <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />