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06/29/2006 12:50 9166385F-11 CASCADEDRILLING - PAGE 02/03 <br /> JUN-n-euuo INU u1 :00 rift aIUriC rim rv�. �Yo, •� <br /> San Joaquin Count^y��Environmental H�aa/�lth nDepartmcnt Unit W Well Permit Applicata n Supplement <br /> .JOB ADDRESS: �! O�j 65 C� � PERMIT SR#:�_ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 I weby affirm that I am licensed under the proviaioms of Chapter 9(commencing With Section 7000)of Division <br /> 3 of the Businoss and Proressions Code and my license is in full force and effect <br /> Li,�Jnset# "Ir N-N'm EuplrationDate: %Ilt ON <br /> Date: 6 -191�:11\—Obcontrac <br /> 9lonature: Tide: g_ <br /> Printed name:_ i,�,,,n \ V' ��`i ( •P_i{�}��ea2. •.7' <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby afrirm under penalty Of perjuryone of the following declarations (CHECK ONE) <br /> -I hava 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 /> }�.I have Find will maintain workers'compensation insuranco, as required by Section 3700 of the Labor Code, <br /> for the perfonmance of the work for which this permit is issued. My workers'compensation insurance <br /> carder and policy numbers are: <br /> Carrier:�_ck _ IJ a.k,rl•,�r"\ Policy Number:_b C \,-La-�_ <br /> I earthy 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 Califamia,and agree that it I <br /> should become subject to the workers compensation provisions of Section 370 of the Labor Cod,,t shall <br /> forthwith comply with those provisions, <br /> Expiration Date:��j---0—7 Signature: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SU8J6CT <br /> AN @MPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAR13 <br /> (fS80,a00.),IN ADDITION TO THE COST OF COMPENSA970N,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PRQVIOED FOR IN SECTION 3706 OF 1'HE LA9OR CODE. <br /> AUTHOR TION FO — ER THAN C-57 SIGNING PERMIT APPLICATION <br /> L— C (signature OfC-67 licensed autharilmd representatiye), <br /> hon:by auuroriza(print <br /> to sign this San Joaquin County Well Permit Application an my behalf. I understand this aldharization Is valid for <br /> one(f)year and is limited to the worhk plan dated an(he Front page of th�applicatiae. <br /> 8.2E.02!Mr <br /> 11210zo ol.mi i <br /> W22/01 <br />