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f: <br />10/1612007 11:53. 9253130302 GREGG DRILLING <br />PAGE 02 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />i <br />JOB ADDRESS: PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION 1( Cid <br />I hereby affirm than: I am licensed under the provisions of Chapter a (commencing with Section! 7000) of Dibision <br />3 of the Business and Professions Code and my license is in full force and effect. Q <br />License #. 6+0C J'�r i E)ttiration Date: J u <br />Date: 1 &7 1 Er <br />$Ignature• Title: i/•c 1Q <br />Printed name: ! <br />X0RK9R8' CO3MP 'ti(ON DECLARAIJUN <br />i <br />I hereby affirm under penalty of,per fury one of the 116II&AM declarations: (CHECK ON E) <br />—11160 and will maintains cbrii(iaste of consent to soWnsure for workers' compertaetion, �s provided for <br />by Section 3700 of tie: Labor Cade, for thtr'perfotmance of the work for which lhis permit iIs issued. <br />I have and wilt nwintatn ' compensation Insurance, as required by Salon 3700 of the Labor lode, <br />fcr'the perkftance of the w ork for which this permit is Issued. My workers' corr)eiu 006 insurance <br />carrier and policy numbers erg <br />Carrier•c..�' it <br />Policy Number. _9510702U/ <br />I certify that in the perforinanc a of the work fbr which this permit is issued, t shag notemON any person In <br />any manner so as to bedorrae subject to the wodors' comlreenaatlon laws of Gafffotnia, atq agree that I t <br />should become subjecf to the workers' campensallon prWslons of Section 3700 of the Lebor Code, I shall <br />forthwith comply with those" <br />? provisions. <br />i <br />Expiration Data: Signet <br />PilritediNarnw. r" <br />WARNING: FAILURE TO SECijk WORKERS' C&PENSATION COVERAGE 13 UNLAWFUL; ANDISHALL SUBJECT <br />AN EMLOYER TO CRIMINAL! P&AL71ES AND CIVIL FINEST Up TO ONE HUNDRED THOUSAND DOLLARS <br />$100,000.), IN ADDITION TO TH9 COST OF COMPEWTION, INTEREST, ATTORNEY'S FEE=S, AND DAMAGE$ AS <br />PROVIDED FOR IN OECTION 3708 OF THE LABOR COVE. i� <br />T FOR Q ER'THAN C-67 SIGNING PERMIT APPi.JCATION <br />t, (signature 0110-S7 licensed auifwrtmd rop"Sontathre), <br />hereby authorize (purr( name): <br />to sign this San Joaquin Caurity,Werl ParmttAppileadon on my behalf. I understand this authorizadat Is valid for <br />one (1) year and 1$ lirntted to the wn+ic plan dated an tine front page of this application. <br />8-29-02 f MI i <br />UM 2M2-0or <br />r�rzvva <br />