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� 1 r <br /> San Joaqui ounty Envirolftmeni al Health artment <br /> Unit IV Well Permit Application Supplement c� <br /> Pe <br /> Job Address: 1?/0/0 <br /> Ph-' rmit SR#: <br /> LICENSED CONTRACTORS DECLARATION CLCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of <br /> the Business and Professions Code and my license is in full force and effect. <br /> License#: 7 p <br /> Expiration Date: <br /> Contractor: e �QICGI^1 Date: <br /> Signature: <br /> Title: � �^��� �f.�.'✓.r4 C�.� <br /> Print Name: L✓ <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 by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> .17 I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for <br /> the performance of the work for which this permit is issued. My workers' compensation insurance carrier and <br /> policy numbers are: <br /> Carrier: ,�.}Q Policy Number: 04L4 Cot) 1-0 C6 <br /> I 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 should <br /> become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br /> comply with those provisions. <br /> Date: <br /> Signature: <br /> Print Name: bo4�i✓ _ Gt 7,>Gt_4x� <br /> Warning: Failure to secure workers' compensation coverage is unlawful,and shall subject an employer to criminal penalties and <br /> civil fines up to one hundred thousand dollars($100,000),in addition to the cost of compensation,interest,attorney fees, <br /> and damages as provided for in section 3706 of the Labor Code. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) C , to sign this San Joaquin County <br /> Well Permit Application on my behalf. I understand this authorization is valid for one (1)year and is limited to the <br /> work plan dated on the front page of this application. <br /> WELLPER USITE <br /> EHD 29-02-001 <br /> SIC Parcel Viewer-Microsoft internet Explorer Provided hy Puhlic Health services r.3 0: <br /> ✓ S. 3 r ' <br /> Yedtkes$ f http ffwebsterrwebsiteJParcelViewergrameset asp <br /> .,.,.... _.._._.__ f <br /> vu :; <br /> Parcel neta�' ` <br /> arc.. :12313=. <br /> m9� <br /> atsoni Rales. <br /> 3Q39Fac Avg; ?' <br /> ....._ ,° �+gAdc1t4tw O <br /> Situs Number 1410_ p <br /> YWA <br /> 9. <br /> f <br /> ... a Sys Tyffe E& <br /> none $. ` i- iiitu City LNJ5r 3 ; <br /> APN Books « <br /> Grid �a <br /> .' : l'aK Ante 1I8U26 <br /> Address _ o br�� � [�o�YearX63nw <br /> a <br /> city Lm its <br /> Photo 2000 Nov fir" I�� - <br /> FwedF�..� <br /> Phato1998Od 1[ r< ' f :' 7:' "••" ..<. <br /> Photo 1994 Mx ,€€. r r: Vakm <br /> Yree vine value U <br /> S. <br /> County Zoning a ° T Imprsve valuE 86159 <br /> Farmland 2002, <br /> ::v ParcelSgFt IQ (F <br /> Partd Acrt4 LJ Z295464113865� <br /> m ; outbklgs Soft .e:Y <br /> Num units <br /> ilEl <br /> f Y�ar iiu <br /> ; wx T <br /> flak"whole <br /> Garage <br /> d . i7 � '` 7 <br /> . <br /> 33'd , _.. , w4i, 7 <br /> .'T ........ .. �yy,,,,���� r;;/ppyy,, _i, qq yy..ma�yy y�yy�yyp y�y� Yy� y �J• y,pyy� <br /> •;. t .. ., 1!IR:l{ !J11. 3 F 'RAK'1C1€i3^',.,.:. ti ���.4..f`�... �SJ4P.8Y�1 a�l� _ lo'[fN'1C...:.r <br /> ':, -. 1 - ✓d xb b�. �` uv a+A<'x dl .Y,db -,v°xRt <br /> ( wdm <br /> P <br /> ...:., .. .rte.- ..- <br /> Friday,Jun 18,2004 11:14 AM <br />