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• 93/30/2009 15: 17 707374 7 PAGE 02/0.2 <br /> 93/27/2009 13:53 530Goes E,Oat(-(fig ATUS NO CAL OL PAGE 02/02 <br /> San Joaquin Coun Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: ')-540 4 PERMIT SR# b :y� <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 and Professions Code and my license is In full force and effect. <br /> License#, NO 07[ Exp Date: <br /> Date: 3-73b - Contractor: 1 L,c)w Cc-I <br /> Signature: diAAAA Title: <br /> Print Name' -lp p <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dedaration% (check one) <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 this 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 wont for which this permit is issued. My workers' <br /> compensation Insurance carrier and policy numbers are: <br /> Carrier: <br /> Policy Number <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 sulijectto workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp, Date: /h lo q Signature: <br /> I <br /> Print Name:, <br /> WARNING:FAILURECRIMINATO <br /> PENALTIIES AND CSECURE IVIL FINE$U�0 5100, OATION o IN ADDITION TO THE OST OF COMPENSATION,INTEREST,RAGE IS UN FUL,AND atiALL 3UWPCT AN EMPLOYER TO <br /> ATTORNEYS PEES,AND DAMAGES As PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AIJTHORIZ%TION FO OTHER HER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 (signature of 0.67 licensed authorized representative), <br /> hereby au rize(print name) 1R1rLf v' T ur to <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 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 /> slavouN� <br /> NR4L PEIiM17MP <br /> GNC29-0+ +H51� <br />