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07/07/2009 12:36 20946587'^ PRECISION SAMPI - 9n <br /> L/ 9- PAGE 01 <br /> WD a E ' �� <br /> - - o <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Appliiccattion Supplemental <br /> JOB ADDRESS: Sk e } PERMIT SR # e) <br /> Tract 1 LF} a sn Io <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: & 344, 397 Exp Date: 1/,31 /ZOfD <br /> Date: Contractor: PI apslOf.) SAMDUAJb 1 NG <br /> Signature: I Title: LOCA-TlotJ MA4JA6t-7C <br /> Print Name:�_t)LA (' WAWFjIW-b <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' Compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> AM EQI GA-1 1 AJTEXJ JA}flON/1L <br /> Carrier: es Policy Number: _6,4- &42. 11 2= (CFr) <br /> llv Su Maa+.� GOM�A-N`� <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if i should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those pro isions. <br /> Exp. Date:_7j L010 Signature: <br /> Print Name: A IQ F);J bA C*AV11FyA-D <br /> WARNING=FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �U�kiQRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, [--oe�—��-.1 (signature of C-57 licensed authorized representative), <br /> hereby authorize(printname) YVOW &YirpnMrAJ Ut SCJVICt'S Int , JOAQ L,4,,Cµ to <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> R/2910s1M1 <br /> EH02q-0'- 1119/07 W LL PERMIT APP <br />