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01 / 04 / 10 09 : 50Ai4 All Jell ,. Abandonment 530 . 644 . 1439 p . 03 San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement 3147 South E1 Dorado St , Stockton , CAPERMITSR#: JOB ADDRESS : .- LICENSED CONTRACTORS 'DECLARATION ( LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profe�sssions Code and my license is in full force 'and �effect. ;2 p 10 `�* 7�� G/A License, #: �� L� Expiratic o Date: Date: iZ �� I �� Contractor: — ( i u7;�1 � - W �n ffif I ....r.<,..-. . .--:_-. ,�____�;_..� _ Title: Wes \U wy Signature: -- -` ,��7--,., r"'" "y - Printed name: WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) _ I have and will maintain a certificate of consent to self-ii isure for workers' compensation , as provided for by Section 3700 of the Labor Code, for the performance: of the work for which this permit is issued . I have and will maintain workers' compensation insuran :e, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is i sued . My workers' compensation insurance carrier and policy numbers are: //�y `` / Carrier: `statt and ... Policy Number: UI 1()0( = 0q I certify that in the performance of the work for which th s permit is issued , I shall not employ any person in any manner so as to become subject to the workers' co.ripensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code , I shall forthwith comply with those provisions. Expiration Date: M"WPrint Signature ed Name: r . WARNING: FAILURE TO SECURE WORKERS' COMPENSATICiN COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES I fP TO ONE HUNDRED THOUSAND DOLLARS PODN SECTION TO THE 3706 OFTHE OF COMP NSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED OR AUTHORIZATION FOR OTHER THAN C ,,67 SIGNING PERMIT APPLICATION signature ofC-57 licensed authorized representative), Daniel Villanueva hereby authorize (print name)_ to sign this San Joaquin County Well Permit Application on n behalf. I understand this authorization is valid for one (1 ) year and is limited to the work plan dated on the front page of this application. 8-29-02l MI EHD 29-02-001 6/22/04