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F,'JG 26 2002 U: 51FIM HP a_HSERJET 320, <br /> r,o�ccs cqn[ 15:b1 46401 p. 4 <br /> _.. .�.. ENVIRONMENTAL HEA,,, <br /> PAGE 02 <br /> F <br /> an Joaquin County Environmental Health 3@rviaes,Unit 1V We11 Permlt Application Supplement <br /> ADDRESS: �eVif- V S PERMIT SR#; a63 lv <br /> G� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby afl7rm that I am licensed under the pravislons of Chapter 9(commencing with Section 7000)of Division <br /> 3 of tho Business and Professions Code and my license is in full force and effect. <br /> Ltceanse*: J Explral on Date: 0 <br /> Date: 1- r <br /> Signature: Tlt1e: <br /> Printed name: cdganedLe <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penally of perjury one of the following decieratlons: (CHECK ALL THAT APPLY) <br /> have and will maintain a certificate of consent to set(.Insure for workers'compensation,as provided for by <br /> Section 3700 of the labor Code,for the performance of the work for which this permil Is Issued. <br /> !have and will maintain workers'compensallon Insurance,as required by Section 3700 of the Labor Code, <br /> for the peAormance of the work for which this permit Is Issued. My workers'compensation Insurance <br /> Carrier and poilcy numbers are: <br /> Carrier: <br /> lacyNumbor: <br /> d•+ <br /> 1 cert#yt tnat In the performance of the work for whlch this permit is issued, I$hall not employ any parson in <br /> any manner so as to become subject to the workers compensation laws of California, end agree that It I <br /> should become subject to the workers'Compensation provisions of Section 3700 of the Labor COdCr I shall <br /> forthwith comply with those provisions. <br /> Date: 0�; 1 ` Signature' 34A� <br /> Printed Narne:40 el op <br /> WARNING:FAILURE TO SECURrm WORKERS'COMPEN$AT1oN COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CKIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND t)OLLARS <br /> IN ADDITION TO THE CO3T OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 5706 OF THE LABOR CODE. <br /> w <br /> 4` 1'rk/Ae� _ (C-67 licensed authortsed repmrantativo),hereby <br /> sutborise <br /> to alpn this San Joaquin County Well Permit Application On My behalf. 1 understand this authorlotlon Is valid for <br /> ono(1)year and In limited to the work plan dated on the front page of this application. <br /> 547.2000 f MI <br />