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P%14.celved Fax: 08124/09 03;19M"Otax Station; All We.'l kbandonnent p,04 <br /> San Joaquin County Environmental Health Department L nit IV Well Permh Appflcation Supplemental <br /> JOB ADDRESS: � ����PC RM1T SR N <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 l,w-1.1 —fr,.... 11-1 1—,II.~.."t..,j" M W6WT14IWOtO yr Ol,,y,l" .*1I "MF.7a401600 TOGO)Vr <br /> Division 3 of the BusinessandProfessions Cade and my lic.nse is in full force and effect. <br /> License#: D9 Jc?, i _ E <p Date: l o i <br /> e <br /> DaterI og Contr2 w el1k. <br /> Signatur Title: <br /> Print Name' 3 <br /> WORKER'S COMPENSATIO11 DECLARAVON <br /> I hereby affirm under penalty of perjury one of the following feclarations: (shack one) <br /> I have and wig maintain a certificate of consent to sc If-insure for workers'compensation,as <br /> provided for by sedion 3780 of the labor Code,for t is perfDrmance of the work for which this <br /> permit is issued. <br /> have rarxt willmai&Aln wnrkPr%'cnmrvensa0on ins urence, as required by Section 3700 of tho <br /> Labor Code, for the performance of the work for whish this permit is issued. My workers' <br /> compensa'.ion Insurance carrier and policy numbers are: <br /> Carrier. m c f _ Policy Numb fr: O1-7 ob <br /> I certify that in the perfornIance of the wor k for whirl I this permit is issued, I shall not.employ any <br /> person in any manner so as to became subject to Ih a workers'compansation law of California,and <br /> agree that if I should become subject to workers'co npensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those Prov signs, <br /> Fin.Mtn:. 41L, I slonatur ' <br /> • SC'1�- ��- <br /> Print Name:�oL <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE t$UNLAWFUL,AND SMALL SUBJECT AN EMPLOYER TO <br /> CRIINNAL PENALTIES AND CIVIL FWES UP TO$100,000,IN AOI I ION TO THE COST OF COMPENSATION.INTEREST, <br /> ATTORfiIE S FEES,AND b"AGES AS PROVIAEO FOR IN SEC-TON 3706 OF THE LAIIOR CODE. <br /> I, U;AUTHORRATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> II (signatur+!of C-57 licensed au;horizsd representative), <br /> hereby authorize(prin arne� _._ ._ . to <br /> sign this San doaq;jiny W0J Permit Appllea on o"f')ehatt. t undorstand this authorizatioll Is valid <br /> for one year and is limited to the work plan dated on the from;page of this application. <br /> anslo2AM1 <br /> f3�}y9Q4 1togr %V-' M%ATAPP <br />