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jo 9253 130302 P. 1 t 05 . 05_1 1 : 08a GREGG DRILLING <br />a <br />111:1 t <br />Cos <br />Title: Signature: <br />Policy Number: 6e)D1Z4O I <br />San Joaquin County Environmental Heafth Department Unit IV Well Permit Application Su plement cli.. <br />JOB ADORESS:2-31') are -7;-/-C(---PERIVIIT SR: <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 farce and effect. <br />License #: ID19-1.D Expiration Date: (0 j 5 ()(0 <br />Date: 51 Contract 10 0 <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I ha.te and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Cade, 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 S(Y hr <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, arid agree that if I <br />should become subject to the workers' compensation provisions of Section 700 of the Labor Code, I Shall <br />forthwith comply with those provisions. <br />Expiration Date: <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 ADOMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 371:16 OF THE LABOR CODE_ <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />\-10.Yu Lx)(1.21.1-1--) (signature crIC-57 licensed authorized representative), <br />hereby authorize (prirrt name)Pt I KO 607,4 A - (IA <br />to sign this San Joaquin County Wall Perrnit Application on my 2haIf. 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 />8-29-02 / MI <br />L. <br />tg nature: <br />U41)29-02-001 <br />9/30/2003 <br />• <br />•••