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iyi <br /> ar• < <uuo 0dAM Romanced GeoEnvironmental <br /> # � No, 4102 P. 3 <br /> San Joaquin County Environmental Health Dlepartm—entUnit IV Well Permit Application Supplement <br /> JOB ADDRESS: /OrIS E- Ru!r�hCJyf PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> LC <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 Cade and my license is in full force and effect_ <br /> License#; (10$o z 2-:1 <br /> Expiration Date:_ ()I(} (p <br /> Date: 3 oZ ev ntractor: a"e )�n�/I/Utl^QIIYYI�/) 1401 ,�t( <br /> Signature: I !!1 <br /> Title: <br /> Printed name: <br /> WORKERS' COMP SATION DECLARATION <br /> I hereby aTfrm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, 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: Policy Number: <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 Califomia, and agree that if I <br /> should become subject to the workers'co"tons or ection 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date; "0 I Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'CE IS UN UL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND NDRED HOUSAND 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. 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 /> EHD 29.02-001 <br /> 622/04 <br />