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RECOVED <br /> pIcko 'iii�unty Environmental Health Department Unit IV Well Permit Application Supplemental <br /> Jg9\APP M ; EaLrN j p 1N- 2 ERMIT SR# <br /> PERM;T/SERV, <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 ancdL Professions Code and my license is in full force and effect. <br /> License#: (/ �� O -f Exp Date: 4 / 3 ( / ( Q <br /> Date: O Contractor: <br /> O, /4/1 do"r 3oI^ <br /> Signature: C Title: r 1 /) (✓ 12" RD �P D <br /> u L`-u . L�= <br /> Print Name: �� �t C . <br /> MAR 0 6 2009 <br /> WORKER'S COMPENSATION DECLARATION ENVIRONMENT HEALTH <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) PERMIT/SERVICES <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 /> Carrier:24 G-ba—A P r1141Policy Number: q 4 0,3 <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 provisio <br /> Exp. Date: `?/ n Signature: <br /> Print Name: R f-r i C C - De- <br /> WARNING: <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 /> I, UT HO TON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATIONA <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to <br /> sign this San Joaquin county Well Permit Application on my behalf. I 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 /> R1291021MI <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />