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Ma;, 13 05 11 : 27a Fisch Drilling 205-772-3571 p. 2 � • <br /> r <br /> =70M : Ground Zero Ana I ys i s � PHONE NO. : 203 838 9883 �-.� May. 13 2905 10:144'1 P3 <br /> San Joaquin County t*riviranmental Health Department Unit N Well Permit Ap <br /> p <br /> li <br /> ca <br /> tion Supplert*nt <br /> JOB ADDRESS: 2360 East S*gyt Trac CA PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that f am Iicensecl under the provisions of Chapter 8(=mrnencing with Section 7000)of Division <br /> 3 of tete Business and Professions Code and my I•Idense is in fuli farce and effect. <br /> License : � _ Expiration Date: _ <br /> Date ,�l "C)S - Contractor: Fya ckk tL1 t tRQi <br /> Signature: r _ Title: W A e <br /> Priiflted name: DAV 5c,� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the Following declarations: ICH>ECK ALL THAT APPLY) <br /> I have and will maintain a certitieM of consent to self-insure for workers`compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> y 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 tl'1is permit is issued. My workers'compensation insLfafl e <br /> carrier and I <br /> iny Trnbl are, <br /> r <br /> carrl4r. DPoticy Npmt�er Ly' ��rJ VVV <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 workers'compensa'Jon laws of California, and agree that iE I. <br /> should bewme subject to the workers'compensation provisions of Section 3700 of the Labor Corte, I stlali <br /> forthwith comply with those provisions. <br /> Datot Yj _Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL Foos uP TO ONE HUNDRED THOUSAND DOLtAR6 <br /> (SW,00mN IN ADDITION TO THE COST OF COMPENSAMON,INTEREST,ATTORNerS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SEC ON 3748 OF THE LABOR COM <br /> �bj�jj C� S i nature efC-57 licensed authorised representative). <br /> ff hereby authorize(print name) John P.Lame,Ground Zero AnkhMis <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for . <br /> one f1}yew and Is limited to tete work plan dated on the fr*M page of this application- <br /> 1.-2"21 MI <br />