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07/07/2004 10:21 209467-8 p >• AGE STOCKTON PAGE 02/02 <br />Ju) 07 04 08:54a �� SI61-wdE'.-9558 F.1 <br />87/87/2004 08:44 2094671118 AGE STOCKTON s�A 02/02 <br />pw)q _ <br />San Joaquin County Environmental aalth Doositment Unit N Well Permit Appticadon Supplement <br />JOBADDRESS:-2—X 1 11, I111" JT/10+ PERMIT SRR: 0O?l? a <br />LICENSED CONTRACTORS DECLARATION Lt <br />I hereby affirm that 1 am ficensW under the prOVisions of Chapter 9 (commenein with riion 7000) of Divisicn <br />3 of the Business and Professions Coda and my (Cone is in full form and <br />Umnee * :4 � ExMration rata: 331 I')S <br />Date' <br />- Co tredor, <br />rem <br />Sim tum <br />/ �,/ % / / ^T -Titin: , f <br />Prinead momr, Ed NIA-% / �l 19 r1 _ LC �I <br />WORKERS' COMPENSATION DECLARATION <br />I hereby offirm under penalty of perjury one of the following declarations: (CHECK ONIE) <br />1 have and will maintain a ceft fieMa of Consent to ea 4rrliare for workers' compensation, as prarlded for <br />by Section 3700 of the Labor Cate, for the pe0armance of the work for which this I fruit is Issued. <br />I have and wig maintain workers' compeneaeon insuranrs, as re4liked by Section 3700 or the labor Cody <br />for the performorece of the work for which this permR is issued, My workers' cornpansafion mxrronce <br />carrier and policy numbersre: <br />Carrier. COIon �riJCSi#4r oGcyNumber.� aO0/��5� <br />I certify that in the performance of the work for which this permit is Issued. I shall not ampfoy any person it I <br />arty manner as as to become subject to tha workars' compensation Imm or Caiiiornul, and agree that if I <br />should bamme subject to the workers' compensation provisions of Section 3700 of rho Labor Code, I sha 1 <br />forthwith comply with those provieicna. <br />Etrplf fibn Date= Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE 1NCMKRRS' COMPIENSATION COVERAGE 15 UNLAwrNI, AND SMALL SUU.ICCT <br />AN EMPLOYER TO CRIMLWAL PENALTIES AND CMA, FINES Up TO ONE NUNORGD THOUSAND 096.AR3 <br />IS100,000,N IN ADDITION TO TH& COST OF COMPENSATION, INTEREST, ATTORNe": FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE <br />FOR 0THER THAN C-67 SIGNING PERMIT APPLICATION <br />outhorite0 represenu ylL <br />hereby authadw <br />0 sign Uris Sai Jeegain CeunH Well Pandit Apprleath m an my behalf. 1 understand thIS arthorJewon Is valid for <br />Me (1) year end In arelftV to me work plan dated ore the front page of thea appnea8on. <br />X19 . 1 <br />snmaaoz <br />