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06/09/00 FRI 09:31 FAX 209 948 0621 003 San Joaquin County Environmental Health Services, Unit IV Well permit Application Supplement JOB ADDRESS: 1fwY t 5 6*--r;u ,y PERMIT 5R#- ,#,I R#:/a1/✓1x—L 1L -h Lv 1 i S 0-71.1 LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. License#: 604987 Expiration Date: OCTOBER 31 , 2000 Date: JUNE 9 , 20100 . -r—or: HE ILLING COMPANY, INC. Signature: Title: PRESIDENT Printed name: H WONG WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers'compensation insurance carrier and policy numbers are: GROUP 059 Cagier: STATE COMPENSATION Policy Number: #000155 - 00 INSURANCE FUND _I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of and agree that if I should become subject to the workers'compensation pr isions of Sec' n 3700 of the L Code, I shall forthwith comply with those provisions. Date: _ JUNE 9 , 2000 I' Printed Name: HEI ONG "JAR!,:;NG: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. I, HENRY WONG (C-57 licensed authorized representative),hereby authorize KLEINFELDER, INC ./THEIR AUTHORIZED REPRESENTATIVE ONLY FOR AB VE), to sign this San Joaquin County Well Permit Application on my behalfNunderstand is authorization is.valid or one(1)year and is limited to the work plan dated on the front p2ge of this application.