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Rpr 04 OS 12:3010 <br />�T i it <br />. Z .. <br />Mitchell Drilling <br />707-444 - 0049 P.1 <br />. 'corms <br />San Joaquin County Environmental Health Department Unit?V Well PermitApp6caCoh �S,uupplement <br />PERMIT. SR#: <br />vv`t v7� <br />LICENSED CONTRACTORS DECLARATION (L.q <br />I hereby affirm that I am licensed under the provisions all Chapter 9 (commerx:ing will► E4Wficn 7000) of Divisior <br />3 of -he Business ants Processions Cotte and my license is In hill fgrna and effect <br />Lioenaet 2617 lSxpiratfonDate: b 30 <br />Pate: _ - Contractor: •NkITe- Ni.[.4- 2P-X-Uy4> 9rJ . COKE <br />Slgnature' <br />Printed mama: PAIL Gf 6 <br />WORKERS' COMPENSATION DECLARATION <br />1 hereby eflirm vnoer penalty of perjury one of the following dec€ar9tioris; (CHECK OIdE) <br />i <br />1 have and v4 malntaln a certifcota of consent to self -Insure Far vvorkars' 0ornpunr atiorn, as provided for <br />by Sedior4 3780 of the labor Cotte, for the perrormence of the work for which this parm 9 is Issued. <br />I t w and wdl alainWn w.W.' compansalion irlsumnea, as required by Section i '40 of the LatDor Cader <br />for the performance of the work for which thio permit is issued. Vy workers' =noer,sation insurance' <br />cartler and policy numbers am; <br />Carrier_ Corgi WID 5lPi�{A cz Y IN S co . Policy Humber; 0 t) <br />I off* that in the tierforrnance of the work rot which Ihk permR is issued, 1 shall r<l employ any person In <br />any manner an as to become sutgect to the workars' componsation favus of Catifarnha, and agree tAat it I <br />should became sutajeat to the workers compensallan pravlsiorm or Section 3740 or she Labor Crxle, i shafl <br />forlhwith comply with those provisions. <br />E7PIration Datta: ! { 0 b Signature: _. <br />Printed Name: <br />WARKINIC: FAILURE TO SECURE V"KERO' COWENSATM COMPA(ae IS LINLAWPUL, AND SHALL SUA.IECI <br />AN EMPLOYER TO 091110NAL PENALTIES AND CIVfL FINES 1113 TOONE 1lUMDREO THCIW;AMR DOLLARS <br />(¢t00 Ot10 b <br />IN ADD=W TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />13ROVIMD FOR IN SECTION 3704 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTNIERTHAN C-61 SIGNING PERI 17 APPLICATION <br />I, P 6 (allinstum &C -W 6eonsed authorized raprvsentauvel, <br />hereby atuhartze (Print name)--•-• I)C)NyrW <br />to sign thla Sha dosgvin County Well PrearR Applkation nn my behalf. I under stand this aWivrUmdore Is valid for <br />one (t ) year and is Ilmited to the work pian dated OB the front pays of 11113 app Ilca(ion. <br />a-x9o� i mal <br />MD 79-07.061 <br />6R2Po4 <br />w, <br />c <br />