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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: PERMIT WP#: --------------------------- <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: --------------------------------- <br />License#: ___________________ Expiration Date: _________ <br />Signature: ___________________ Title: _____________ _ <br />Print Name: Date: -------------- <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />□ <br />□ <br />Carrier: <br />I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br />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 />-----------Policy#: ______ _ Exp. Date: _____ _ <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 PENAL TIES 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 />l, ___ �,m-.�otc::= .. =1L�, .. -, ... �Au-... � .... � .. -..... -.1a11vo------, hereby authorize ___ p= •• �,.�om-.�o1 Au� ... -.... � .. � ... ------- <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 />Signature of C-57 Ucensed Authorized Rapreuntatlve <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Penni! Application <br />in Caltrans SR 26 right of way next to 22401 SR 26, Linden, CA <br />Gregg Drilling, LLC <br />C57: 1044456 <br />Laura Gregg <br />Project Engineer <br />Laura Gregg October 26, 2021 <br />Axis Surplus Insurance Co SP002682-04-2020