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06/11/2007 11:36 707374 WOODWARD DRILLOCO PAGE 03/03 <br /> PAGE 88/03 <br /> 05/11/2007 08:10 53867 5 STRATUS NJQAL1 <br /> 5 Ib <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application�Suupplle�ment <br /> JOB ADDRESS:, Ll 1115, O K si. buk lit PERMIT SR#:�UJ L!� <br /> LICENSED CONTRACTORS DECLARATION (-LPD <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 Code and my license is in full force and effect. <br /> Expiration Date: <br /> License#: � - <br /> C n <br /> Date: - <br /> Contractor: 1 <br /> Q ,_TIYIe: <br /> Signature: ° <br /> r <br /> Printed name: <br /> WORKIiRS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing deolaratlons. (CHECK ONE) <br /> provi <br /> orkers' corn <br /> sation <br /> by Section will f maintain <br /> LabcertificaOf consent or Code far the perfoormalnaie of the wonsure for rrk for which th snperm t is issued <br /> for <br /> I have and will for the performancetain workers'of the work for which this pensation hsuran nnit is issued requiredoe, As Mworkers corvtpensatlon insurance ode <br /> carrier and policy numbers are: <br /> � <br /> Policy Number:ll'11 t_, QaLD� <br /> � <br /> Carrier: <br /> I certify that in the performance of Use work for which this permit is issued, I shall not employ any person in <br /> any manner so as to became subject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Sectlan 3700 of the Labor Code, 15hatl <br /> forthwith comply with those provisions. <br /> Date: In \\� n 'I Signature: <br /> Printed Name: <br /> OE IS UNLAWFUL.AND SHALL <br /> AN MIP OY RTO CRIMINAL-pENALTIE6 AN'COMpENSATIQN D GIYIL FI P TO ONEHUNDR D THOUSAND DOLLARS <br /> UBJEGT <br /> ($100,0ogj,IN ADDITION TO TPROVIDED FOR N SECTION HE OF THEPL1BOR OMPENO COMPENSATION,INTEREST,ATrORNEY'S FEES,AND DAMAo;E5 AS <br /> 70 <br /> AUTHORIZATION FOR ,OWNER THAN C^57 SIGNING PERMIT APPLICATION <br /> Q�II/i 7ni i (signature cfC-57 licensed authorized representative), <br /> t J ,c'^rua��-�--- <br /> horebyauthofse rintname) �v�v" r <br /> Lone(l) <br /> San Joaquin County Well Pprmlt Application on my behalf. I Understand this authorixaNan��?valid for <br /> r and is I�mited to the work plan dated on the front page ofthlF application. <br /> I �-� <br />