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02/30112006 09:20 5102374574 PRECISION SAtIPLING PAGE 02/02 <br /> AUG. 29. 1000 2.43PM TERRASEARCH INC N0, 4821 P. 2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit A=picatio,, pplement <br /> JOB ADDRESS: (,;-D���'"(.rnt �a PERMIT SR#: <br /> ?6L <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I horeby affirm that I am licensed under the provislons 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 /> 6 3 (0 3���" I<xplratien Date: 31 -�,Ue- <br /> Date: <br /> "o�/ Contractor: i o til so-� uvqs, )Vic— <br /> Signature, <br /> Vic -Signature,7`� /�~ Title; <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and WIII maintoln a certificate of consent to self.insum for workers' Compensation.as provided for <br /> by Scelon 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> I <br /> have and will maintain workers' compensation Insurance,os required by Section 3700 of the Labor Code, <br /> � <br /> or the performance of the work for which this permit is issued. My workers'compensation insurancF <br /> oarrier and policy numbers are: <br /> Carrier: <br /> �,.{j�y� ��H Policy Number: �� � � �� ,v �a �3°I- <br /> I cerfiry that in the performance of the work for which this 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 the workers' compen©ation provisions of Section 3700 of the Labor Code, t shall <br /> forthwith comply with those provisions_ <br /> 7o p 7 Signature:-2M <br /> provisions- <br /> Expiration Date: _ ^- �--`— <br /> Printed Name: i,�e <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE Is UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (s10tl,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 /> AUTHORIZATION FOR OTHEFZTHAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-67 licensed authorized representative), <br /> 1, <br /> hereby authorize(print name) <br /> Lto sign this Sari Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> ono(1)year and is limited to thr work plan dated on the front page of this application. <br /> S-2g-02/Ml <br /> CHD 29•(32-wI <br /> 612210d <br />