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LING PAGE 02 <br />.�� X00 r 16:26 925313W --l- <br />;'EGG DRILL.,......._ ,,, ,..,. - , .._•._.,.. <br />8yy51r115 $ /� t° <br />San Joaquin County Environmental Health Department Unit N Well Permit 'Application Supplement <br />SOB ADDRESS:_ �(]�p A ,/,4 ¢PERMIT SR#. <br />Sic k+car, C -A qr 10 6 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm that 1 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 force and affect. <br />i <br />License / Expiration Date: <br />Date: 2 Contra, <br />Signature: Tltie:�?T�'Lr <br />Printed name: <br />WORKERS' COMPENSATION. DECLARATION <br />1 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 Ensure for workers' compensation, as provided for <br />by Section 3700 of the labor Code, for the performance of the worts for which this permit is issued. <br />forand will maintain wormers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the worm for which this permit is issued. My wormers' compensation insurance <br />carrier and policy numbers are: pp <br />Carrier: ��t � - f, Policy Number-, C3(c>t <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 Calffomia, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall <br />forthwith comply with those provisions. <br />i <br />Expiration Date._ fi I C}�� Signature: <br />1 <br />.Printed Name: r T <br />WARNING: FAILURE TO SECURE WORKERS, COMPENSATION COVERAGE IS UNLAWFUL., AND SHALT. SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL, FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />AUT ZATI FOR OTHER THAN C-87 SIGNING PERMIT APPLICATION <br />(elgr12tur+e 01C-57 licensed authorized representative), <br />hereby authorize (print name) �f r% 5 <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authort atlon in valid for <br />one (4) Yloar and is Ilmttsd to the work plan dated on the front page of this srppllcatfon. <br />5-29-02 / MI <br />RHD 29-42.00E <br />6J22R14 <br />