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02/02/07 14:54 FAX 916 434 4206 PC EXPLORATION Z002 <br /> FEB-02-2007 14:41 IDE <br /> RIR . P.02i02 <br /> San Joaquin County Environmental Health Deeppja�rtment nit IV Well Permit Application Supplement <br /> JOB ADDRESS:ZJ ia) G -f✓�Q�y� "'` w PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 Code and my license is in full force and effect. p <br /> License#: t7 Expiration Date: <br /> Date: '�-= 7��2-- t77 Contractor: 7 �`�1� <br /> Signature: -� Title: l`i( (i 1,1c McN a;Z e-r <br /> Printed name: So e F1,Z�' ~ <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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-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 /> ce, as <br /> on <br /> 0 of <br /> or <br /> forthe performance the work for this permit snissued required Myworkersecolmpenst compensation inan Code, <br /> ce <br /> e <br /> carrier and policy numbers are: / � 1 <br /> Carrie r6ornW6�Le ��USI �°icy Number: <br /> 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 California, 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 /> Expiration Date:'1116;-7---signature: _ <br /> Printed Name: S C)in in P r(C H^ L A <br /> COMPENSATIONWARNING: FAILURE TO SECURE WORKERS' <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARSUBJEc7 <br /> (Sloo,aoo.),IN ADDITION TO THE M SECTION 37 6 COST OF <br /> THE OMPBOR NSATCODE!ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED OR <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC571icensed authorized representative), <br /> i, <br /> hereby authorize(print name) <br /> it Application on my behalf. I understand this authorization is valid for <br /> to sign this San Joaquin County Well Perm <br /> one (1)year and is limited to the work plan dated on the front page of this application. <br /> 8-25-021 MI _ - - <br /> DID 29.02-001 <br /> 6/22/04 T"r <br />