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I .! I > , <br /> tB9/12/2002 1 H7 191663P0S11 CASCADE DRILLING INC _PAGE_ 02 <br /> (.Njt S I U.K I VI'{ <br /> ,9;-12/2002 '13:94 2094( jy18 1 <br /> San Joaquin County Environmental Health Depar*Wbo 11VWA Pglmi "cat' t <br /> County Envlronmerdai Hearth OepeRment Unit N Well Permit APPIIcati°n gupplement <br /> JO �e&S. PERMIT SR# <br /> PP <br /> JOB ADDRESS: 14 ti I HeRryTA.J w PERMIT SRS <br /> 9szy S <br /> LICASD ED AC <br /> CONTRTORS DFS V ) <br /> LICENSED CONTRACTORS D <br /> I herle <br /> by affirm that am licensed under the provisions of aty�r �8tj9g�y(tg6daA0WtdalQtNtl9i9i ion <br /> 3 of ��ttf f SGtOpAaG t/f1@�t Rl °s r 'tU t <br /> 3 of the Buainosa and P ofeaaimte Code and .... M.. 4�' e <br /> Lice #: E (jt ( - ,' I <br /> Licerse p:eI <br /> Date: or tLr { n <br /> : r <br /> Signatµ�rl� <br /> C <br /> Print@ Y <br /> �r�1i� pp��ggpp��-ffppN DECLARATION <br /> WORRERff�COMI'EpNSATION DECLARATION <br /> or oyrury one of the following declarations (CHECK All 7 APPLE � Y <br /> I herelb�h1'f0W 4�t9@} I�a� ertury 01%00 <br /> ne of the following declarations: (CHECK AL THAT eX r b <br /> nd war maintain a cat!ftcete of consent to self-insure for work"'compens ,ltOn baaa <br /> I have 8it#IB&LcAMfiNt%o(ocampetf&WW4*t �ftYAA?kLh�s�'gPp n'sation, as provided for t(y <br /> S t l have andhwillLmainta abor odwo ka,s campengglion e, for the nsu anhce asrregtjr�tl oy a��i��blgn�y�°r Code, <br /> r s e . M w kers comPe^aahon inwrance <br /> e agdpibwoftt8asN9tht�+JcHd �rff°��fie,aa� )eque��y Section 3700 of the Labor Cod , <br /> fo the pataed¢roi�rfyth+11W2A1P Pw Ich this emit is issued. My wo kjs'�o ur�nce <br /> carrier and poliCq�Ucii��(arQre �Q-�Qna Policy Number: �v` <br /> Cariel: r e word oPI*IWj"aq"b t is issued, i shall not employ any pe sort In <br /> jfytitaHn-tite-peilonnaneC o th <br /> WE <br /> nor so s to become subject to me WorKeR'compensation taws i181f L i shall <br /> —I certify LIB �BG�2 � ter pl�in+eflals er ( s °Ps71 no emp employ any person i <br /> any mar)B h epprtyb�c�peetrlbo0a3 workers' a ation aws of California, and agree that if I <br /> should become sssuub ect�w�ers' compen io rov' of Section 3700 of the Labor Code I shal <br /> fo co ' ftnatun: \\ // <br /> tm Name: .�G���� <br /> Date: <br /> SF ure: <br /> WARNING:FAILURE TO E 'URE woRitrRB'COMPENSATION COVE <br /> AN EMPLOYER TO CRI p11ES AND ClCV FINES UP TO ONE HUN �T � O D M CIES A3 <br /> f 100 DOD. ,IN ADDITION TO THE COST OFF COM11 TIoft�NT'EftES <br /> WARNIN�pIt ,FNIT <br /> R@FZ9t i3 l9RWON COVERAGE IS UNLAWFUL,AND SHALL SUBJEC <br /> AN EMPLOYER TO ND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), l DDIE COST OF COMPENSATION,PROVIDED F70�9F T�r.+/ arn, 71C LLLA <br /> hel�Y euthortxt=) <br /> nems) / ---- v �. <br /> 1, well Permit ApPllcattan 6f6.%/t`*And Ta tut razed re r veld ear <br /> -tp3igrrdiis San�eaouin G°unty P�$� Icensed authorized representative) <br /> hereby aU ;gt(pp9heamtied w the work Pian dated on the*Ord Page of this eppatallon. <br /> to sign orization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 1-25-02/MI <br />