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Apr 04 05 12:30p Mitchell Drilling 707-444 9049 P-11 <br />-CA <br />law, <br />San Joaquin County Environmental Health Department Unit IV Well PermItAppixeCon SuppleMent' <br />JOB AnDRESS: PERMIT. SFt#, <br />LICENSED CONTRACTORS DECLARATION %RD <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commO(ft-ingwith �ecbcn 70(x3) of Divaiar <br />3 of the Business and Pralanions Code and MY 1100.88 Is in full fnr— and effect <br />Liceroe# i5 �7�Expiratlon Date: <br />Date; <br />Signature: r Title: <br />Printed name: <br />WORKERS' COMPENSAMN DECLARATION <br />I hereby . offirm unUer penalty of perjury ane of the following decliratiori%: ICHECK ONE) <br />I have and will maintain a oQr0rc*t9 of consent to self -insure far wofkam'c*mPerts-ation, as Providtd for. <br />by SBc*mS7Df) of the Let br Gode, tomhe perfonronce of the work far which JNj piTwlt is issued. <br />I h. and vrV maintain kr.' compensation insurance, as reqLlrod by Section2.-00 of the Labor code. <br />W the performance of the ywrk for which thio permit is Is5ved. my wnmw-9* comDarsation insLaanco <br />carer am policy numb era are: <br />Carron e,;AFAijjW -WU-1A � '� I P5 GO policy Number; &7 <br />I certify that it the perWmarcc of ft work 11of which thla permit is issued, I shall rdcl employ ary perwn In <br />eYy mWer so as to bnorna subject to the workers' compensation laws of Galdon-,ka, and agree that if <br />should become subject to the woFkem'wrrtp&nsatjon provision-- or Sec. -tion 3700 Lf .he Labor CLAe, i stall <br />forthwith comply with those provisions. <br />Expiration DM: j Z? 11 0 6 aignature. <br />Pr(nted Name: Q PIQJ <br />WARNING: FAILURE TO SECURE WORKERW COMPENSATION COWRAGIE, IS UNLAWI;tJl-, AND SHALL SUBJE97 <br />AN EMPLOYER TO CRMNAL PENALTIES AND OWL FINES UP TO ONE HLINDRED T"0U3AX0 OOLLARS <br />(4190,900.), 04 ADOMN TO THE r,05T Of U011APENSATION, INTEREST, ATrORNEY'& FEES, ANO DAMAGES <br />PROVIDED FOR IN SECTION 3Y04 OF THE LABOR COW, <br />AUTHORIZATION FOR Q T14AN C-67 SIGNING PERMIT APPLICATION <br />1, P,,� G sr- 6 —(signature ofC-57 (ptrisod at ,dio FULd reprosentaftel, <br />hereby mo.orb!p (prfnk rmmc)_ <br />to sign this San jWvin Couaty Well Pormill Application Dn my beholt l understand this a uthortmdon la valid for <br />one (1) year and is limited to the work plan dated on thL' front Page of We applIcaam. <br />8-2"2 f M1 <br />14TI3 79-02-wl <br />W2104 <br />