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VN '4) E <br /> r <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: w �^ u// PERMITSR # <br /> 1. <br /> I <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> ( hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License #: 'l X 'I 5 r o Exp Date: o i . 3 I - 'o <br /> Date: 10 /28/22 Coe Contractor: Cascade Drilling , Inc <br /> Signature: i % operations Manger k <br /> i <br /> Print Name: Tony JaramillO <br /> WORKER'S COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self4nsure for workers' compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> ✓ I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> Compensation insurance carrier and policy numbers are: <br /> Carrier: Aiu &%L , ryw.; .Tr. Policy Number. DY Gw s o'er 3 i _ <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 the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: G5 . k . 'l _ Signature: ioo� <br /> Print Name: Tony Jaramillo <br /> WARNING: FAILURETO SECURE WORK <br /> ERS' PINES UP TO $10 COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL PINES UP TO f1e0,000, IN ADDn10N TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES A8 PROVIDED FOR IN SECTION aTW OF THE LABOR CODE, <br /> THORiZAT ON FOR OTHER THAN C47 SIGNING PERMIT APPLICATION <br /> 11 ignature of C=57 licensed authorized representative), <br /> hereby authorize (print name) -)p , to <br /> sign this San Joaquin county Well Permit Application on my behaff. I understand this authorization Is valid <br /> for one year and Is limited to the work plan dated on the front page of this application, <br /> areemvur <br /> f <br /> Esc zno„ irsor xEu e�aurc NV � <br />