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04/07/2_004 14: 06 191663 11 CASCADE DRILLIN INC PAGE 02 <br /> 6 <br /> — ---_ 4/07/2('04 13'36 109`11 _ A .AGE STOCKTON � YNat uu"` <br /> ox <br /> —��sin County EtrvlronmenLgl Health 0 gKment Unit IV Well Permit Application Bupplemer t <br /> San Joeq qp <br /> JOS ADDRESS: L45 W. r 1YiV F PV- PERMIT SR*:_- 103 <br /> LICENSED CONTRACTORS DECLARATION <br /> I herany Lftlnh that I em licensed under the provisions of Chapter 9(cemmaneln9 wltti 5ectlOn 7000)of Oho cion <br /> 3 of the Dusirmw and prafeasiorts Cada and my license IS n full force and Ellett <br /> License C-57 -� 7 If-2 ri�� �Mpirat`nM1on C4ta: <br /> Date' tra c�Lsr�lA7 rY��-\�= 1� <br /> Slgnawae: <br /> Printed name: - <br /> W01il ` COMPENSATION DECLARATION <br /> I hereby afQrm under penalty of par ury one foilowing deolarationa: (CHECK ONE) <br /> 1 have any will maintain a certificate of ovnac::t:o*W-insure forwartrers'cdmprfnpafion,as provided 1-.r <br /> by Section 3700 of the Lobo Coda.for the p«,ilvmarlce of the wudt for which thl$permit a*sued. <br /> I have and will maintain work4rs'Compensation insurance,as required by Sactid 3700 of me 1_abOf G ade. <br /> for the parrormance of the work for wr ich this permit is issued. NN workars'compensation Insurance <br /> corner and Policy <br /> nurn"rra e: <br /> Carrier: 1 1`�1�1�� IV AClfl I Policy Number: <br /> I certify Qat in the perfor nence of the work for whiW thls permit Is iWi I $hall lot employ any perso,.in <br /> any manner so as to became sublent b the workers'eompertsaticn laws of Calitr:rnio. ora agree trial n 1 <br /> nnouid cecnrne suNect to the workers'compenotlan pro . .ons of 5e "en 3700 of the Lat5ar Coda. 14 has <br /> forthwith comply w-iillh those prcviaidns, <br /> Printed Name: n - -- , <br /> WARNING:PAILUR6 TO SECUFM WORKZRS'COMPEN"rJON COVLRAGC i5 UNIAAWIUL,AND II Wei,=CT <br /> AN EMPLOYER TO CRIMINAL PENALTV9 AND CIVIL FIN1$UP 70 ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),Nf 4100MON TO TH6 COLT OF C,QMPaN>SATiCn>INTEREST,ATTONWY'S PEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3704 OF THE LABOR CODE- <br /> AUTHORI NYOOR <br /> r �R.THAN C-57 SIGNING PERMIT APPLICATION <br /> I, V �� `^e4 wi.a�('lynature ate-6711unaed authorized vp- 6 nbdwl, <br /> . hofthy authortp)print naLy' T 4 V ._._ <br /> to sign this San Joaquin County Well Parma Application an my bahaR- I understand Mi.t authorisation Is valid for <br /> one(1)year and N Ihn w to the work plan dated on the front page of tins application. <br /> La_R!-pS/MI —J <br />