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05/27/2005 FRI 08:55 FAX 2003/009 <br /> MAY 27. 2005 9:46AM CON,,.,-, EARTH TECH %fte NO. 1202 K 3 <br /> San Joaquin county Environmental Health Department Unit IV Well Permit AppiicatiOn Supplement <br /> JOB ADDRESS: 00 /URS U1z1L)E PERMIT SR#:- 4—t <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Cade and my license is in full force and affect. <br /> D <br /> License#; ?G9Csc/ Expiration Date: <br /> Date: o� 7 S-contr4V- <br /> 'Signature- / ,7TitlPrintodname• K/ � kA 'e R <br /> WORKERS' COMPENSATION DECLARATION ' <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-Insure for workers compensation,s provided for <br /> by Section 3700 of the Labor Code,for the performance of the work far which this permit is issued_ <br /> 1/I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued_ My Workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: h� �� Policy Number: 4-/ <br /> 1 certify that In the performance of the work for which this permit To issued, I shall not employ any pewon in <br /> any manner so as to become subject to the workers'compensation laws of California. and ogree that if I <br /> should become subject to the workers'compensation provisions of Section 5700 of the Labor Coda, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: <br /> Printed Name: <br /> GE IS UNLAWFUL,AND SHALL <br /> WARNING; <br /> PLOYER TOC IMINAL PENALTIES AND CIVIL F ES UP TO ONSATION E UBJECT <br /> HUNDRED THOUSAND LLARS <br /> AN EM <br /> ADDITION To HE COST OF OF THE COMP NSAT ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED PON EGf ON 3 <br /> UTHORIZATION OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I (signature o1057 licensed authorized representative), <br /> 1 <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understana this authorization is valid for <br /> one(1)year and is limited to the work plan dated an the front page of this application. <br /> 6-29-02/MI - <br /> E3 M'29 02-00i <br /> Gn2/04 <br /> RECEIVED TIME MAY. 27. 10: 07AM 05/27/2005 FRI 08:32 ITA/RX NO 55551 931003 <br />