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JA14-23-04 04 : 12 PM lt INC. <br /> 760 8572 P. 02 <br /> va ciisuuY lc is rre�tl LEEKS DPI LI'JG PqC. 02 <br /> 40N—$1—a4 02159 bN lEr INC. 765 O69 9577 P,132 <br /> than Joaquin County EnYlronmontal Hugh Department n t IV Well PertnR Appllcatlanupp omsnt, <br /> JOS ADDRESS:—I&L-La�t go-vitra,i�— PERMIT SR#; <br /> LICENSED CONTRACTORS DECLARATION (1.1fe—D_,) <br /> i noreby affirm thdt I am licensed undor the provlsions 91 Chapter 0(eommer ting with SOUVOn 7000)of DIV'alon <br /> 9 of the Ousiness end Profe��ssiion&Code and my license is In full fo,ee and effect. <br /> License N, _ _. / . P ° Expiration ult <br /> DeM:�/1Q�contractor, a 4'.LS <br /> Signature / Title; (� <br /> Printed name, _ [ rw _— <br /> WORKCR9'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pelury one of Ihe1o11owlnq iectoretlons; (CHECK ALL THAT APPL'n <br /> tl0m,06 <br /> IBhaveeol on S7COwill <br /> o the Labor Coda,far th Aerfarnsnoe of the week forkwhich this pesremll a laeuodvleI <br /> I have and Wir maintain worker!'COrnpenaatidn 1%u/an A,as required by secaon 3TOC of the Loc?Code, <br /> for Ire parfarmanoe of the work Por which this permit IS ieaued. My workoro'oornponsallon Insu•s of <br /> an•ar and policy numbarA Are; <br /> Carriers G�1ttt�-------- <br /> ►alico Number: <br /> cen ry that In the par}anana d the work for wh(ch thlc permit is Issuad,I snail not eTploy any person In, <br /> arty manner loo as W become eubJoct tc the wo"I`ora'O"Porsll"l wa et 3700Califofh,end or C Mal If I <br /> should become oub)om to the workers'compensation plovtalors of Section 5700 of Labor Cadb,I chart <br /> forthwlih comply with those Drovlalons. <br /> 1 Zce Signature <br /> Data;��__— / / <br /> Printed Noma <br /> 13 <br /> {AWARNINO� FAILURE TO SteCkJolle aN EMAI O)YIGR TO CRIMINAL PENALT as AND CMEPtNltspP TO ONKERMa N�UNDRaD THOUSAND DOLLAR UlJECT <br /> /RONDid,IN ADDITION <br /> TO TMal <br /> I Of T"OF co OR CODE,ON.INTEREST.ATTORNCY'a Pelts,/u+ODA M tie As <br /> 1psturs OIC-57 nconoed authorized rrprowtattw), <br /> bereby wthorlae(Print nsmo4------ <br /> to <br /> te sign this San Joataule County Well Pormlt Application on my behalf. I understand thle aulha�x44ion la yalid for. <br /> ono it)loss?and Is Ilmlted to filo work plan 04404 on the front reale of this application. <br />