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Sent By: Gregg Drilling & Testinr Tnc. ; 925 313,ru'`G02; Dec-14 8:57; Page 1 /1 <br /> San Joaquin County.Environm.ental Health Services,.Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:_ a_I �����C3Y� . (�L�et�.�_ PERMIT SR#: 2 l d <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect. <br /> License#:, `J� �� Expiration Date, <br /> Date: ( Contractor: r <br /> Signature: _ I � Title.,-- �) C.Q M CY <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the foliowing declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> ✓ I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, . <br /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: �iQ-0 � Policy Number: -� � <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 California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 37 of the Labor Code;I shall <br /> forthwith comply with those provisions. <br /> Date: 0o Signature: <br /> Printed Name: <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100-,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,AT'TORNEY'S FEES,AND DAMAGES AS <br /> PROV . ED FOR IN SECTION 3706 QF THE LABOR CODE. <br /> 1, (C,57 licensed authorized representative),hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Applicatlon on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 5-17-20001 Ml <br /> Z0 3SVd 60074 H1dIJ EEbE89b60Z ZZ:60 000E/PT/ZT <br />