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10/12110 21:43 All well andonment 530.644.1439 1 p.02 <br /> Received Fax: 10111110 04:39 Fax Station: A11 Well Abandonment P.03 <br /> n Joaquin County Eovironmental Hftlth Department <br /> WELL$ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS. — PERMIT SR# -LL i 5 U <br /> �-oGc_-�-��, C �• GI S2 � <br /> i <br /> LICENSED CONTRACTORS CIE CLARATION (LCD) <br /> I hereby affirm that I am ficensed under the provisions of Chapter 8 (commencin(; with section 7000) of <br /> DIVilsion 3 of the California Business and Professions Code and my license Is In full fotce and effect. <br /> (`I <br /> License#: �T J Exp ate;_ <br /> Date: C Q <br /> Signature: _ ..R. "= "__ -- --`Title: _... <br /> Print Name: <br /> WORKERS' COMPENSATION I] CLARA"nON <br /> I hereby affirm under penalty of perjury one of the foliovAng doc arafions: (chuck ane) <br /> —f have and will maintain a certificate of consent to elf-insure tier workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for a performance of the work for which this <br /> permit Is Issued, j <br /> i <br /> I have and will maintain workers' compensation Insurance, as required by section 3700 of the <br /> Labor Cobs, for the performance of the work for w ich this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers a <br /> Carrier: Pollimy Number: <br /> I certify that In the performance of the work for which this permit is Issued, I shall not employ any <br /> person In any manner so as to become subject to Vie workem' compensation law of Galifarnia, <br /> and agree that if I should become subject to workers'compensation provisions of Section 3700 of <br /> the labor Code, I shall forthwith comply with those pmoy ions. <br /> IExp. Date: ::Az: Signature:�•� -T"-� � 3 <br /> Print Name:, <br /> WARNING:FAILURE TO SECURE WORKERS COMPENSATION COVERA0919WFUL,AND SHALL SUBJE 'AN EMPLCIYEMR TD <br /> CRIMINAL PENALTIES AND CMI.FINES UP TO 5100,000,IN A011 ON YO THE COIrr OP COMPENSATIOK INTEREST, <br /> ATrORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SZCTIOit qZT05 Of Tit LABOR COBE. <br /> AUTHQRIZA. TION"R OTHER THAN C-57 S14'1 IMG PERMIT APPLICATION <br /> Curs 0 -67 licermsed authorized reprasentative), <br /> h0sby author (print name) <br /> to sign thGl� Ian Joaquin County Ws11 It, Boring Permit <br /> Application on my Behalf. 1 understand th authorization Is vat d for one year and is limited to the work <br /> pian dated on the front page of this application. <br /> 002" 0740110 <br /> MLL PORW P <br />