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No . gun <br /> Sep . 26 . 2001 4 : 031' M Adv ed 6aAnvlronm : ntal <br /> 1 � <br /> EnVlranmtrntal Health Department Unit IV Wel( permit Applicatlon Supplement <br /> San Joaquin County <br /> JOB ADI]RESS : O`{ CeS� rC V PERMIT SR#, y y <br /> LICENSED CONTRACTORS DECLARATION (L_CD) <br /> I hereby affirm that I am licensed under the prou+sions 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/mff ct O <br /> License #; I l� Expiration Dttatte' _ <br /> CT <br /> Date: ! d C t or, C L> e)l �ul n <br /> Title: <br /> any <br /> Signature: <br /> Printed name: DO n <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-inure 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 /> compensation 3700 of <br /> I have and for the performance ill of t worke for which this openmitr snsued My workers, coce, as required by mpensation tinsuranee Labor ode, <br /> carrier and policy numbers are: �} � l C) 2-(.Q ` <br /> Carrier: SS 'r Policy Number: 1 <br /> I certify that In the performance of the work for which this permit is Issued , I shall not employ any parson in <br /> any manner so as to become subjeot to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation previsions of section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: � Uc .+ Signature: . ...( ' <br /> Printed Name: Ch rt heyr� �r <br /> WARNINGI <br /> OYER TO CRIMINAL P9NALTIES AND CIVIL FINES UP TO ONE HUNDREp THOUSAND SUBJECT <br /> AND DOLLARS <br /> AN EM <br /> PROVIDED OR N SECTION 31as j$lliljv000r) IN ADDITION To THE O THE OMp NSATJON, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> T 0 ER THAN CwV SIGNING PERMIT APPLICATION <br /> � .�, (signature ofC-57lleensed authorized mPmshr`tativei, <br /> I <br /> h <br /> ereby authoda ' (p <br /> rant name) ART e <br /> ign this San Joaquin Cpunty Well Permit Application on my behalf. I understand this authorization is valid for <br /> (1I year and is limited to the Work plan dated on the front page of this application. <br /> 9421 MI <br /> 8HD 29-Ga-GGI <br />