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Title: <br />Contractor Name: Gregg Drilling <br />License #: <br />Signature: <br />Print Name: Ch,: j' <br /> <br />Expiration Date: 01/31/2018 <br />0/6tor.e?75a2-- //70.70,,e, <br />Date <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 5N) §.. lqgkilig§litti8,ettodi, CA PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />1 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 />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 />0 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: _R_T- -CfeCla7//4X C-f—cn <br /> <br />Policy #: Date: 8/37 be <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 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 />Signature: <br />Print Name: <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 />Cr61/2 -- <br />NP11141. at C.67 [Icon ad Aallmazod Rordosoatollvo <br /> <br />, hereby authorize Cheryl Cary <br />Pent ti.ono al Autbormed Aoonl <br /> <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 lim'te to tvo plan dated on the front page of this application. <br />Smaalato at t.t7 L•con sod A and Aepresontoliro <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application