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iLu io:cc rnt ULU 177 41U1 V W DRILLING INC 0 401 <br /> ` -ate <br /> or V/07/2000 10: 04 209-579- S MODESTO a i C � PAGE' 01 <br /> 1 i-tb8-1,999 1 to: i t ort FROM Q � <br /> } <br /> s <br /> San.fosqu'sn county Environmental Neakh 11wVicee,Unit IV Well Permit Application Supplement <br /> l JOB ACDRESS:INN- �6mjt.�.S��K�� PERMIT SR*-. <br /> �"'� rrwr.. j <br /> � f!I <br /> I <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that) am lkensed under the provtglOns Ot Chapter 9 (Carnmenang with Saction 70001 of Mvrsiert <br /> 3 Gf the Swsinesa Ana Prokssions Cade fond my license is in full force and effec-t. <br /> ILwAnse I6: Expiration Date: <br /> Date: C pitractar: ► _-- _ <br /> Sigr+lttum" Time._ <br /> WORKERSr COMPENSATION JDECURAT1ON <br /> e I hereby affm ur;drar penalty of perjury ohe of the 1`4011OWng deciarstidns: (CHECK ALL TWAT APPLY) <br /> i <br /> ! . I have and will maintain a iv$Ofleate or consent 10 self-irriurs for worksm'compensation. as provided 10r py <br /> Soe.Oon 3707 of the LBbw Code,for the performance of the work for which this perrttif Is irsuk, <br /> i <br /> I have mid will maintain"r+cerf compensa>ion insurance.as require4 tsy Sec%on 3700 of the Loator Code, <br /> 'or the Aecfermsnce of the work Cor wrikh tit's permit a issued, My wo**rs'=mpensatiun insurance <br /> CaV*f and policy nvrnbers are; " <br /> Carrirr. -Policy Number f' - <br /> i <br /> _I certify ftt In fhe performartioe of the worts br which this permit is issued. 1 shag not employ any gemon in <br /> any manner so as to becerrte i5cbject to the Jaws of California,and agree trot if i <br /> should becorn 9Lbject 10 the workers comWsation provisions of Sect' rt 3,T00 of vie Labor Code, I snail <br /> (ortl'vihth comply with Chow prpl+4sionS. <br /> yy <br /> mte.. sn1-QS! Signature: <br /> Pfirlted Name;��� y j: 12a <br /> WARNING: FAILURE TO SECURE WOI FIRS'COMPENSA"ON COVEKAGO IS UNLAWFUL.AND SHAt.L SUBJECT <br /> ! AN EMPLOYER TO CRIMINAL PENALTtE9 ANO CML FINES UP TO OtNC 4Uft0ACt YHDUSA?40 DOLLARS i <br /> tOO,Ot}0.1, IN AoolrioN 1.0 TK COV OF Cates PMATION,INYElRE9'r.ATTORNEY'S KIES,AND CAMRGES AS <br /> PROVIDL'O FOR pit"ECTiON"00 QF TME LABOR GOPI," <br /> • I <br /> 11, (C-ST licensed autheriaad re Prose ntativsl,hgreby <br /> A�i <br /> II autAorz� \f w L4v� CY l��''' &ot..4-4 <br /> to sign this San Jwouin County Well Pormit ApglioaWn Oh.my behalf. I urdamta nd thie Autharlaatlon is valid for <br /> one 01 Year and is limited to the work plan datgd on the from 4 Of alis aryoliestion_ <br /> 03/07/2000 TUE 09:05 tTX/lig NO 52041 Q1004 <br /> k <br />