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■ ■j 02/03/2006 10:52 2094658- SPECTRUM EXPLORAT?ON PAGE 01 <br /> ■ M 12/ l'kl;, j- f.lGb r�U 2UA'Uli'34ba OINS-925-9?9-978.1 FIFTH FLOOR * NO. 3325 HAp 211 <br /> ■■Y <br /> —kt ] <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit App <br /> tication Suppiern f <br /> Z <br /> JUB ADDRESS; 34PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION } <br /> I h.reby affirm that I am licensed under the provisions <br /> of isCapter has full force9 (Oorn d effect, <br /> License <br /> with Section 7000)of Division <br /> 3 c,f the Business acid Professions Code and my license <br /> License#; A XP <br /> Expiration Data: <br /> Date:�= _Contractor.� CT- c.r <br /> Qom/ Title, l e Cit4T)o N /t')aN �2 <br /> Siclnature: <br /> PH'nted name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I h areby affirm under penalty of perjury One of the following declarations: (CHECK ALL THAT APPLY) <br /> _ I have and will maintain a certtf�te of consent to self <br /> •insure for workers'compensation, as provided for by <br /> -Section 3700 of the Lebor Code,for the performance of the work for which this penrit is MUsd_ <br /> _I have and will maintain workers'compensation insurance,as required by Section 3700 <br /> 0of t assurance he Labor ode, <br /> for the performance of the work for which this permit is Issued. My workers'comp <br /> carrier and policy numbors are: <br /> i:atrler:N � <br /> eoAt„ U.ulpe! 4 Policy Number:��� '�f 7?B - <br /> to a<< rfTT , Pik in <br /> _ I carti that in the performance of the work for which this permlt is issued, I shall not employ any p <br /> - ect to the workers'compensation laws of California,and agree that If <br /> any manner so as to become subj <br /> should become subject to the workers <br /> forthwith comply with those provisions. <br /> Date, 0 Signature: <br /> Printed Name: rZ <br /> yVJ'JtNING; FAILURE RIMINAL PENAL IIE3 AND CIVILEFINES UP O ONE HUNDRED THOUSAND DOLLARS GE IS UNLAWFUL.AND �E� <br /> AN EMPLOYER T <br /> pSRDVIDED,IN AD SECTIO THE O EFLAgO�L�OSCE ON,INTEREST,A7'fOF2Nl;1('S PEES,AND DAMAQE <br /> (signature ofC-67 licensed authorized representative), <br /> iL/ <br /> hel'aby authorize(print name) rce <br /> to r4n this San Joaquin CourdyWell Permit Application on my behalf. I understand this authorization Ix valid for <br /> ons(1)yeer zod Is limited to u%work plan dated on the f mt page of this aPPlication. <br /> 5-17-20001 MI <br />