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San Joaquin County Environmental Health`D,ep�fa-�rtmepn.t.Unnd iV Well Permit Application Supplemental, a rL I. <br /> JOB ADDRESS cj ST%11 RktIT SR yf <br /> L1IC'ENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licanseti under Or-prT,vlsions o1 Chap,er 9 (cori'nencing with Section 7000) of 1 <br /> O v:sroll 3 Of the Business and Prolessians Cftde anti my Iipense is in Tint force and effect <br /> E Lace tse '1._: (oExp Date 1 3 t 2-012 <br /> Late 51561 �onttaelor }2EL15t(7n] AM�LiIJ�it��, . <br /> Signature Titre i-C{LA-i 1 wF t tJF t i <br /> I <br /> Pint 1\1ame � � r r rgt' �_..:_ <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm-under penaffy of perjury one of the following rc"eclaratioris (check one) <br /> 11nave and will Maintain a, cerhf cate of consent to self-insure for c ceF,ers con pensa;ton, as <br /> provided for by section 9700 of the lab*(Code.forVhe perfornla,ice of the work for which alis <br /> e peer it is,issued <br /> } <br /> Y _t have arm will maintain worice;s compensation insurance,as reouved by Ser:tron 3700 of the <br /> Labor Code, for the perfoimarlm or 4ile work for which toys permit is issued duty workers` <br /> ,i �oillf3eRSatlOn tnSUranCe Gafifr:F?ilii 3?Ol,ry YYtltTlge CS are: �.., <br /> TtMEAI t.F+af 1+ti.I7+w"riNAT7fh+17iU '�' � I <br /> Carrier: PS0FC1dA & Policy Number, ( 74 D— <br /> I eethf. Inat in the pertorwaoce Of file mrk for which tf'is lentil Is,fssfuetf i snail not employ any <br /> r person in any manner4so Us,o fatiaorne subjeat to the wor"I rs' crimperi8at:nn jewel't;allfovua,and <br /> agree trial it I should tl£:tonle iiubject to vrorFers'Goinjl ansafron pfovisions orf Section 3700 of the <br /> _ Labor Code 1 shall Ifii(ifwrth fomply Mtn those p1 a3VZ,Mlons ( ... <br /> Exp. Date; (c 3U7-U 10 Signature, <br /> Print Name:: <br /> i <br /> WA-RNM; FAILURE 7O=£.".URE.wORKERS"COM�ENSAt10N GOYERAGE 15 UNLAWrU4.AND5trACt SUBJECT Ak -MP4oYER TO ff <br /> CRIMINAL PENAt.Ties AND GWit riN£S UP 1`01100,00,01 ADDITION To plF COSTOF COMPENSATION !NT£RFS7,. 1 <br /> I .A'noRNE--s FEES,AND DAMAGFS AIA PROVIDPO FOR M SEC4IDN 3106 OF THE LASOR C.Ob£. <br /> f <br /> �`- t1TNC PJZATIQN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION 1 <br /> fsignalure of C-57 licensed authorized represemat volt <br /> hereby authorize{print name) O`1 i {�_ i SLG Q7 I71 . Q A-T4. to <br /> ' sign thls San Joaquin county Well Permit Application on.my behalf.. I understand this authorization is valid I. <br /> for one year and is limited to the we&Plan dated on the front{rage of this apprica Fion. <br /> III <br />