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02/20/2007 13.39 9166385611 e0 CASCADEDRILLING <br /> LV LUV/ 11 : ISHNI NV 'gcep VeOtnvlrofinertdiPAGE 02/Dsg <br /> ie� No, /689 P. 1 <br /> D� 271 g 6,1 Lr�F\Cas <br /> San Joaquin County <br /> Environmental Health Department Unit N Well Permit ApplicatiolSupplement <br /> JOB ADtiRESS�2f/D3 PERMIT SR#�Oo5ob555��`j <br /> 2 IS0 'i� :5 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Crapter 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 k= S-1 Q Expiration Dante::: <br /> Date: — — Q _Contractor G� Irl ,` Y 1 (_ n[� <br /> Signature; Title' �+2 ( d rN', <br /> Printed name; I "Tony r Dara ►vI e l o <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of tho following declarations (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-Insure for warkam'eompensatlon, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work ferwhich this permit Is Issued- <br /> ' I have and will maintain workers'compensation insurance, as required by Section 3700 of the LabW 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:f-1lo ; N (� <br /> � -�ioyla I Policy Number; <br /> ] 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 workars'coihpensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions or Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Expiration Date; 0 1 Signature; r� <br /> Printed Name; ( LrWe i <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE ISUNLAWFUL,AND SHALL SU9JECT <br /> AN EMPI-OYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ANO DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUT RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 6 (signature ofC•57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorizatlon Is valid for <br /> one(t)year and Is limited to the work plan dated on the front page of this application. <br /> 8.29.02 1 MI <br /> EHD 2902-001 <br /> Fnamn <br />