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66/19/2003 09:59 1916638'-1 CASCADE DRILLIN VC PAGE 02 <br /> C6/10/20P.3 17;P29946764mo, <br /> � <br /> i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Applicationn Supplement <br /> JOB <br /> ti <br /> B ADDRE$St G�ItJ� �g PERMIT SR#:�i.Lw <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby atfl m thit 1 em Ikensed under the provis)ons of Cheoter 9(commencing with Section 7000)of Division <br /> 3 of the SusKms#ld Professions Code ant my license is in full force and effect. <br /> U cone 4: 57 <br /> Expiration Date: /-,3/-C) <br /> / <br /> Con r�Q�C 4x Gam!�I ! �r /l �J 1�✓l C h <br /> Signature: Title: Q �� r,�n <br /> 1iPrinted name: G►�C— _ lif'l a <br /> WORKERS' COMPENSATION DECLARATION <br /> I i heret y Jffnm urger penalty of pequ7 one of the following declarations (CHECK ONE) 1 <br /> I have we will maintain a Certificate of consent to sslf4nsure for workaru'compensation• ae provided for <br /> Iby Section 37 p of the Labor Code, for the performance of the work for which this permit is issued. <br /> iI have anti will maintain workers'compensation Insurance,as required by 5dcWn 3700 of the Labor Code, <br /> 'Gr the per`orr iance of the work for which this permit is 'saved, My workers'compensation insurance <br /> carrier end pollky numbers/am: / / <br /> Carrier. �II /VQY(�✓I I Policy r. <br /> I certify that inithe performance of the Nrtxtt for which this permit i0 'SaUCd,I shell not employ any person in <br /> any manner"as to become subisct to the workers'componeetion !awe of California, and agree that if I <br /> Should becomesubject to the workers'ComPonsation provisions of S ction 370(1 of the Labor Code, I shall <br /> forthwith eomty,with those proviatons, <br /> I <br /> /I� cats: Signature: <br /> PoniedName �� G Gl a V — <br /> // WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAQC 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL FfiN ALTI"AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> is 00,000.),IN ADD!'(ON TO TWE COST OF COWENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> iPROVIDED FOR IN SECTION 3706 OF THE LAWR COOK, <br /> AUTHO ATI FOR OTNER THAN C-51 SIGNING PERMIT APPLICATION <br /> I <br /> I, (signature ofC-til IlaaMsed"Shorleed representative), <br /> i �v � � t \ Gi <br /> hsreoy authorize(Pont n ) -T ✓, <br /> to sign this San Jotri County Well Fsnnit ApfAcatlon on my behalf. I understand this w4hor zotlon Is valid for <br /> one 11)year and is limited to the work plan dated en the front Page of this application. <br /> LB-29.021 MI <br /> a- <br />