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�� 1 5P <br />Nov 51 23p <br />GREGG DRILLING <br />Horizon Env, Ina <br />9253130302 <br />916 939 2172 <br />P. 3 <br />San Joaquin County Environmental Nealth Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS;_?_ZS �f a,kI ,%� <br />PERMIT SR#: <br />(/�Z (� <br />I Sf oc G.-�-4. <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I a^i IiCenSed under the provisions of Chapter 9 (commencing with Section 7000) of Divisiol <br />3 of the Business and Pmfes5,ons Coda ana my Ilcense is in fui! force and effect. <br />LiCerSB #. O�. Exp ration nate: _ D 44 <br />I Date. t 1 <br />Signature.- <br />Printed <br />ignature: <br />Printed na <br />P•2 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (C HECK ONE) <br />_ I have and will maintain a certificate of consent to self -insure for wa Krrs' compensanon, as prov ded for <br />by Section 3700 of the Labor Code, for the performance of the work for which this barmit is issued. <br />_ <br />" I nave and will maintain workers' compens8tion insirance, as roquired by Scct'on 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 rumbe,s are <br />Carrier: C�T� m Policy Number --2,42) DR � 4 <br />certify that in the pericrmance of the work for which !his <br />permit is issued, I ;he11 not employ eny pefsun in <br />any manner so as to become subject to the worke,s' compensation laws of California, and agree that if <br />shou'd become subject to the workers' comp satlon prov Bions of Section r of the Labor Code, 1 shall <br />fortl'witn comply with those provis ons. <br />Date: _ ! 115 1 dT Signature: <br />lorinted Name: Oaa <br />WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAcG ; IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER To CRIMINAL PENALTIES AND QViL FINES UP TO ONE r 'r:CRED THOUSAND DOLLARS <br />t510J,000), IN ADDITION TO THE COST OF L010PENSATiON, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN 110-57 SIGNING PERMIT APPLICATION <br />l1' — (signature otC-57 licens@d authorized representative), <br />I <br />hareby authorize (p t name) <br />�Q, <br />�,oto s yn Uiis San Joaquin county Welmy ehal . t understand this authorizaf.on is valid for <br />II onQ (1) year and is limited to the work plan dated on the front page of this application, <br />