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X12/2$/09 05:38PH All Yel' handonment 530.644.1439 P.02 �rfl <br /> Rmeived Fax: I2/28J09 43;04eFax Station; All tie ll Abandonment `r p.02 <br /> PhA <br /> Iv Ia <br /> San Joaquin County Environmental Health Departmen-I Unit IV Wellf Permit Application ftpiomhnt <br /> JOB ADDRESS: we, PERMIT SR#: ()!5q 21 <br /> a <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Cha iter 9(commencing with Section 7000)of Division <br /> 3 of ttlr RI Isinr=m rW PrnfPrininnn EWA and mY lire.n,ct in in itil farm nild fiftr <br /> License#; -1 Expiration Data: 1 LV <br /> r� 4 1 <br /> Date: L- <br /> � Contr =rCA QlpnmA�--t <br /> - <br /> Signature: <br /> Printed nameN-r) t <br /> WORKERS'COMPENSATKIN DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to selfwin:iure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance l the work for which this permit is issued. <br /> 1 have and will maintain workers'compensation insuranc�:,as required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which this permit is Issued, My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier, Q'lA(2±C E ))�a 6� Policy Number:�i�� <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'con pensation latus of California,and agree that if i <br /> should become subject to the workers'compensation previsions f Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Expiration date: SignatureL -- __ <br /> Printed 4eame: �„ ,,_ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION:COVERAGE is UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,),IN AD©iTION TO THE COST OF COMPENSATION,11 ITEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDE()FOR IN SECTION 3705 OF THE LABOR CODE. <br /> AUTH T ER THAN C-617' SIGNING PERMIT APPLICATION <br /> b to Onature oM-57 Ilcensed authorized representative), <br /> Y , <br /> hereby authorize(print name) (�( <br /> to sign(Isis San Joaquin County Well Permit Application on retry behalf. I undomtand thle authorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front p too of this application. <br /> 8.29-021 MI <br /> 9M 29-02001 <br /> 6122104 <br />