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02/20/2007 13:39 9166385611 CASCADEDRILLING PAGE 02/0rU <br /> rer. �V, [uv1 111 Isr+lyl ria""cea ueotnv_I ronmental VQ, W9 F. 2 <br /> bry a F�Cos <br /> -Noe <br /> San Joaquin County Environmental Health Department Unit N Well Permit Application Sulement <br /> .2/S/ X00 5066 <br /> JOB ADDRESS! 2103 �� PERMIT SR#:— <br /> Ob C) Sob tr <br /> 2 /SO <br /> --co <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. p <br /> License* SI Expiration Date! <br /> Date; - 19 - C Contractor <br /> Signature: Title:���' ( d r vS— <br /> Printed name; I II Tpr"I.4 j <br /> I ar- m c) <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of tha following declaratlons: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for w❑rkam'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 /> - <br /> 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 workars'compensation insurance <br /> carrier and policy nnuumborr are, <br /> Carrier: "i(ac7q" K (-�'( n yl <br /> I PolidyNumber; <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 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I Shall <br /> forthwith comply with thcaeprovisions, <br /> Expiration Date; 0- 17Signature; q _ <br /> Printedv Name; i ab ue.i t1 ( Ja ` affll_f i ( 0 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND$HALL SUSJCCT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION $706 OF THE LABOR CODE. <br /> AUqTkI9RIZATI0N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> {signature ofC.37 licensed authorized representative), <br /> hereby authorize(print name) � LEE_ <br /> to sign thla San Joaquin County Well Permit Application on my behalf, I understand this authorization Is valld for <br /> Lone(1)year and is limited to the work plan dated on the front page of this application. <br /> a-29.021 Ml <br /> SKID 29-02-001 <br /> Fmm,, <br />