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N <br /> Apr , 6 , 2010 10 : 44AM Advanced GeoEnvironmeotal No . 6 �p � , <br /> Gf. � �l <br /> A, ? F U 9 L I <br /> ENVIRUNMtNI HEALTH <br /> San Joaquin County EnVlronniental Health Department Unit IV Well Permit Application SupPE61 f k RVICES <br /> JOB ADDRESS : r . VfVM(7n t `AVI Mkt?11kn PERMIT SR#: S vlt 5 t <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Cade and my license is in full force and ofTect, <br /> License #; Expiration Date: <br /> lT� <br /> date' a Contract : <br /> r' Signature: —_ Tltlo: Ahte. Cra <br /> Printed name: �tA & f iA2 tot I 0 � ej <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm undsr penalty of perjury one of the following declarations: (CHOCK ONE) <br /> I have and will maintain a certifloate of consent to self-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br /> I have and will maintain workens' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued . My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: A&Lne=jr41C .. C Policy Nambur, C,, Z-(Sean `) Cy <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner ao as to become subjeot to the workers' rompensation laws of Californle, and agree that if I <br /> should become subject to the workers' compensat n provisions of Section 8700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: I r� / It 0 Signature: <br /> Printed Name: <br /> WARNING: FAILURE To SECURE WORKERS' COMPENSATION COVERAUK IS UNLAWFUL, AND SHALL SUEDECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,0e0.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AU RI2ATION PCiR OTMSR THAN C•57 SIGNING PERMIT APPLICATION <br /> I, /L� <br /> �'" (4i0naaura ofC-67 licensed authorized reproaenfative), <br /> hereby authorize (print narrta) X4 L.�"1Qa J_.I <br /> to sign this San Joaquin Cnenty Well permit Application on my behalf. I understand this authorization Is valid for <br /> one (1 ) year and is limited to the work plan gatud on the frant page of this applloauon. <br /> 8-29-D2 / MI <br /> slug 1g-0x.001 <br /> 6/22104• <br /> Ova <br />