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AUG 15 2003 4: 03PM HP LASERJET 3200 p.2 <br /> Rua; 15 03- 03: 25p -Her <br /> N%V/1n Env. chic 816 gas 72 p. 2 <br /> San Joaquin County Environmental Heakh Department Unit N Well Permit Application Supplement <br /> JOB ADDRESS:"3' � .f'#�rr,.Sfi PERMIT SRM: DU 7,-,w F _ <br /> 2.. _ . <br /> LICENSED CONTRACTORS DECLARATION. (LCD) <br /> ! hereby affirm that 1 3m licen3ad"under.lbe.provisions of.ChaWer"9(c;ornntencing with-Section 7000)of-Uivision <br /> 3 of the Business and Professions-Code--anti-my license is in full force and effect. <br /> LlcenSP :�� � 7" Expiration Date: f /0 <br /> Q Y <br /> f� S " <br /> Date:-F <br /> Signature: _ - -- TNks" t2 <br /> Printed name: <br /> WORK S'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I havp and will maintain a certifioate of consent to*elf-inoure for workerrs'cunllensatiort,as provideo for <br /> Zctian 3700 of the Labor Code;for the performance of the work lot which this-permitis issued. <br /> _ and will maintain workars'eompansation insurencc,aa.ecluiredhy.6ectian 3700-of Hie Labor Code, <br /> for the performance of tte-work-for+whichtms permit Is issued. My workers'compensation insurance <br /> carrier and policy numbers are; <br /> Carrier: t _ Policy Number: c,1+ LA 6 q I <br /> I 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 tQbecorne"ect to.the_workers.Compensation,aws-aCaWornia, and agree that if l <br /> should become sobjectto-the-workws`compemsation provisions oMection 3700 of the Labor Code,1 shall <br /> forthwith comply with those provisions. <br /> Date: Signature: l <br /> Printed Name; 1"t a-" CU�tcA -e--►'L-" <br /> WARNING:FAILURE TO SECURE WORKERS`COMPENSATION'COVERNGE1SVWAWFUI.,AND SHALL SUBJECT <br /> AN EMPLOYER'10 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (;100,000.),IN ADDITION TO THE COS I OF CORMSATIUN,INTEREST;ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORI//Z-Ali}t@.I FORO-THER Tt+AN 07;57 SIG'RifNG"'PERMiT"APPLICATION <br /> (signature atC 57 i0ensed authorized representative), <br /> hereby authorize(print ttame).. S►n't c ��i�' l�f � : <br /> to"sign this San"Joaquin County Well Permit Apptieation on My behalf. I understand this.ailthorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8.29�02liNl - - <br />