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10/06/2003 10:42 209334'-"74 WGR SOUTHWEST h" Al_ PAGE 04 <br /> Oct 06 03 11 : 25a t6 .,e woodward 1 -71. . •374-5677 P. 3 <br /> 7.9f96/2003 09.% 2093345374 WGR SOUTHWEST NOCnL PAGE 03 <br /> Cv �.0 C� L�3 — 3 ,a,u,. <br /> son Joaquin County Environmental Health Department Unit N Well Permit <br /> Application Supplement <br /> J08 ADDRESS: CA4 .AM _Em?I- i S Cw G PERMIT SR#: CO25530 <br /> POA V<416011�0-\ 0 <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I em licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Susinan wd Professions Code and my license is i1 full force and effect. <br /> License#: Dcplration bate: ^3 _ O S <br /> Today's Mata: /QC� Z C-57 Contractor: <br /> Signature; , �_� Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby efftrtn under penalty of P"ury one of the folktwinq declarations: (CHECK ONE) <br /> —I have anti will main teln a Certificate Of Cement to self-insure for workers'compenetavon,as provided 1br <br /> by Section 3700 of the Labor Code,for the performance of thq work for which this permit is issued. <br /> I have and will maintain w0*0r8'compOneaGon insurance,,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is lesued. W worksm'compensation in&urance <br /> carrier and policy numbers am: <br /> Carrier. Polley Number: <br /> I cerliy that in the performance ef'the work for whlch this permit Is lasued, I shall not employ any person in <br /> any manner so os to become,subject to the workers'compensation laws of GAlifornie„nnCl ree that <br /> N I <br /> should become Subject 10 the workers'cnmpensallon prOvi9ians O Section 3700 of that <br /> forthwith comply with those provlsions. ofber Ct thth I t3 <br /> Expiration 0( <br /> Dew: Signature: <br /> Printed Name: <br /> WARNING:FAILURE Tp SECURE WORKERS,COMPENSATION COVERAGE 18 UNLAWFUL.AND SHALL sunjECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSANn DoI.LARS <br /> (9100,00.),IN ADDITIDN To THE COST OF COMPENSA'"ON,INTEREST,ATTORNEY'S RtcES,AND DAalAG63 AS <br /> PROVIDED PDR IN SEcTtoN 3786 TH <br /> of E LAIDpR CODE. <br /> AUTHORIZATION FOR +0__THJR THAN C-57 $ZONING PERMIT APPLICATION <br /> t, <br /> (aig"llure WC-a licensed ruth0r1zDd rvpresentati.*), <br /> 4.rs�y eulhorize,(print nd,r,q, <br /> to clgn this San J"quin CaWnty Well Permit Application oh mfr boherf. I understand this who r <br /> rrraAton is vrilltl for _ <br /> One(1)year and is!united to the*a&pistil dabd on the front page of this application. <br /> AR9+42/IIA! <br />