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APR-06-2005 13: 11 FROM:PRECISION SAMPLING 510 237 4574 TO: 19259381610 P.1/1 <br /> I <br /> Apr 06 05 01.42p post-It*Fate 7671 caro Y or P1 <br /> JT- Aages� I <br /> To T Sp... { ��- 1 4 <br /> From i <br /> Co./Dopt. <br /> /~� c.- n <br /> Co. <br /> Phone p Phone k <br /> Fax X t S 8 G 1t Fax k <br /> San Joaquin County Environmental Hea111i Department-EFfflUVW-ell Permit Application Supplement <br /> JOB ADDRESS:0 E. �e�� _� .,�.k--% sl `_ PERMIT SR#: <br /> LICENSED CONTRACTORS DIECLARATION (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 Code and my license is in full force and effect <br /> License# 6 3 63B 77 1 Expiration Gate: I 0 6 <br /> Date- `� 6 Contractort¢. o` S� n <br /> Signature; I Title- <br /> Printed name. �, c,, I �- <br /> -r <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following de Ilaratlons: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-Ins i re for workers'compensation, as provided for <br /> by Section 3700 of the labor Code, for the performance o.the work for which this permit is issued. <br /> —I have and will maintain workers' compensation insuran ce.laa 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: L, o '7 A-itj s Policy Number: �c- Z I �' 133 g• <br /> certify that in the performance of the work for Yfiich tNs permit is issued, I shall not employ any person In <br /> any manner so as to become subject to the workers'compensation laws of California,and agree that If I <br /> should become subject to Itte workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forlltWth comply with those provisions. <br /> Expiration Date: (,3- 38L,:,S Signature: l <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100.000.),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 /> 1�r RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I• slgl ahure ofC-57 licensed authorized roprenwrdative), <br /> herby a rite(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand thle authorization is valid for <br /> one(1)year and is limiter!to the work plan dated on the frontpage of this application. <br /> 8,29-021 MI <br /> DiD 19-01-001 <br /> 6mMa <br />