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66/19/2003 10:46 191663 015CADE DRILLIN# PAGE 02 <br /> Q,gr'19!'2E93 <br /> 10:57 1109Y E .AGE 5T0r-_ .T0N PAGE 02/02 <br /> I <br /> san Joaquin County Envibnmentsl Health Departrnsnt Unit -Well Permit AppNcatlon Supplement <br /> JOB ADDRESS: YypS ArLLICZ 0.1&'i".— PERMIT 5RO7 Xze ' q)q <br /> SqF <br /> T q:x-r=- c,n C� <br /> .LICENSED CONTRACTORS DECLARATION (LCD <br /> hereby affirm t 0t I am Ijeansed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 01 the Ousines8 and Professions Code and my license is in full force end effect, <br /> License* `7,''71'7 I IQ n^EXpiratbn Date:, I ` •d( - O <br /> Date Co r <br /> Signature: Title: -��->y► + <br /> IPrinted name: yQJ' -�— <br /> WORKERS' COMPENSATION DECLARATION <br /> t hereby 8flirm under penalty of perjury One of the following dedarationW (CHECK ONE) <br /> I Neve and will maintain a cerdflcate of wrisent to self-Insure for workers'rompenaelion, as provided for <br /> -'-'by Section 3700 of the Labor Code,for the performance of 1ha work for which this permit is issued. <br /> 1 have and will maintain worksra'compensation Insurance, as required by Section 3700 of the Labor Code. <br /> for the perfoer♦renee of the work for which this permit Is issued. My workers'compensation insurance <br /> Cartier and pal icy numbers a�ml' <br /> Carrier:�,� '"""__".Policy Number: _z .IA) ]� 'r5`-„`-'-...._..,._._..- <br /> I certify that inl the performance of the work for which this permit is issued. I shall not employ any person in <br /> any manner so as to become subject t0 the workers'eompeneaGan laws of California,and agree that if 1 <br /> should becorrle subject to the walkers'compensation prov s of ion 3700 of the Leber Code. I Shall <br /> forthwith com0iy with those provisions. <br /> 1 pate: (n 'Raj gklnoture:_ -- <br /> Printed Name: <br /> i <br /> His DTNUU � <br /> WINU;FAILURE <br /> TOSECURE <br /> INES UP TO ONE, UNDRE SAND DOLLARS <br /> ML PENALTIES AND CML F <br /> (d1tltl,000.1,IN ADDITION TO 711E COST OF COMPENSA'nON,INTEREST,ATTORNEY'S PE88,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE <br /> - <br /> AUTHORIZA71 N FOR OTHER THAN C-57 SIGNING PE,RM17 APPLICATION <br /> i l64 <br /> (A ✓1'—' (^ (a14nstun ofC-57 licensed autholred rePresentative), <br /> hereby authorize(pried nsms)_ f 1 <br /> M �t `" "�.. CA <br /> to sign this San Joaquin County Wall pent Application on my behalf. I understand this authorbstlon is valid for <br /> one(1)year and is Ymitad to the work plan dated an the front Me of this application. <br /> SAML—Ml <br /> s. <br />