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Sent 8y: HP LaserJet 3100; JetSuite; 19-Aug-08 16:04; Page 1i1 <br /> ww A 7/ztqu j 14:08 925685 <br /> HULTOREN-TILL IS <br /> 3PAGE 01/61 <br /> I ? � I I _ sem <br /> San Joaquin County Environmental kealth Department Unit IV Well Permit Ap licatl <br /> JOB ADDRESS; �acoh �cta�aj 3483 M. 131 �" P On SUPpiernentatl <br /> � 4�A -.._.— PERMIT SR of 0,51515 <br /> LICENSED <br /> ' 5518LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the Provisions ` <br /> Division 3 of the Business and Professions Code and myCcenpsel (COrrMencin9 Is in fui'force and etffect, <br /> Section 7000)of <br /> Exp Date:_—/ 5� _ �7 � <br /> Date: j � — � _ _ <br /> -- <br /> `- -- Contractor:_,__77 <br /> Signature: __- <br /> Title: <br /> Print Name:_19Ai Y 1— <br /> WORKER'S <br /> WORKER'S COMPENSATION DECILAPA,rION <br /> I hereby affirm under penalty of pequry one of the following declarations: (check one) <br /> 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 performana;e of the work for which this <br /> permit is issued, <br /> have and will maintain workers'compensation insurance, <br /> Labor Code, for the performance of the work for which this permiittlis a sued eMy Workers'of the <br /> compensation insurance carrier and policy numbers are.- <br /> Carrier: <br /> re.Carri®r: <br /> Policy Number: <br /> I certify that in the performance of the work for which this permit is Issued, I Shap not employ any <br /> Person in any manner so as to become subject to the workers'coripensation law of California, and <br /> agree that if I should become subject to workers'compensation PrOvisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those pro vlsin <br /> Exp, tate.—_64- I ------- - �j__ <br /> Print Name: <br /> WARNING;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRfMINAI,PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTPREST <br /> ATrORNE1 S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-$7 SIGNING PERMIT APPLICATION <br /> --- __ (signature of C-57 licensed authorized <br /> representative),authorize (print name) <br /> Sign this San Joaquin county Welt Permit Application on my behalf. I underE Land this authorization Is validt0 <br /> for one year and is limited t he work plan dated on the front page of this application. <br /> 81201021M v- <br /> C"021-01 115W VVV <br /> WELL P6RWT APP <br />