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08/30/2006 09:20 5102374574 PRECISION SAMPLING PAGE 02/02 <br /> Auc, 29, 2006 2,43PM TERRASEARCH INC N0, 4821 P. 2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: GI'z>,.,�uwv- r4tail PERMIT SR#: <br /> C: 1�20,- U5-D-0"L, .-03, ,.-pLi1 -05, - 10) —off <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am 3 of the Business and Professions ons Codo provisions of Cater 9 <br /> license Ishn f ( o9 <br /> full force and effect. with Section 7000)of Division <br /> I,icer�t�e#: <br /> rxplration Date: <br /> Contractor. i�Y�C�Stoyl S&n uInc. <br /> Date: <br /> ////jjjj��/ Title; <br /> Signature:72t <br /> Printed name;41 �(_-r 174G� <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of penury one of the following declarations: (CHECK ONE) <br /> I have and WIII maintain a certificate 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 /> LI or <br /> and will maintain workers'compensation Insurance,ss required by Section 3700 of the Labor Code, <br /> I the performance of the work for which this permit is issued. My workers'compensation insurance <br /> oarrier and policy numbers are: <br /> L <br /> Carrier: , �j..�,,� Policy Number: �C �3 -?I ,v 7a�3�1- <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 so as to pscome subject to the workers'compensation laws of California,and agree that if I <br /> should become oubject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date, 3v 7 Signature: – <br /> Exp — -- �_ <br /> Printed Name• ! <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (sjoa,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR iN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORI7-ATiON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 11 (signature ofC.67 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this-authorization is valid for <br /> orle(1)year and iS limited to the work plan dated on the front page of this application. <br /> 8.29-02/Ml <br /> 1:14D 29.02-001 <br /> 6/22104 <br />