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�� �_:�y �, ,,, 5� „�SCADEDRILLING PAGE 05/06 <br /> 10/20/2004 16. 25 9166385611 CA <br /> i � - .. -pl L,w U J.]/%)I'I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:22-5 S. � OiE 4t/. 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. <br /> License#: 7/7 S/D Expiration Date: <br /> Date: /v o AT Con actor. <br /> Signature: Title: <br /> . / <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pelury 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 /> 1�I have And will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:l4L S'�� /� /e'i✓�G Policy Nurnbeir;_®J�E�'tI,53,0. 3l _ <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In <br /> any mariner 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 th Labor Code, I shall <br /> forthwith comply with hose provisions. <br /> Expiration pate; 5lgnatur•e: ./ IL,�el <br /> Printed Name: �N AA"G <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FiNES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> b (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is flmlted to the work plan dated on the front page of this application. <br /> 8,2902 t ml <br /> IrAD 29-02-001 <br /> 6/2.2/04 <br />