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05/18/2003 16:16 191663 11 <br /> 05/;8/2003 16:06 166 CASCADE DRILLINC PAGE 02 <br /> 18 AGE STOCKTDN <br /> FADE 02102 <br /> i <br /> San Joaquin Oounty Environmental Health Dapertmant Unit N We11 Permit <br /> APPnptlOn supplement <br /> J013 ADDRESS; /0/ Soyr 7so�I fit/ PERMIT 3RD: <br /> i SToGKTo/� C�} <br /> • ILICENSED CONTRACTORS DECL4RATfON L( CQ) <br /> i <br /> I hereby afr rr n that I am licensed under the C Ii <br /> 3 of the 9uelneee qnd Profesoions Code and my 6consefis In Nit fp9rr(,e w'�3eaian 7000)of Division I <br /> I License Y Z 1 1 t� d O fi <br /> 1 Expiration <br /> Data: ntractor. C <br /> 1 <br /> Signature: 1 <br /> Title: („ <br /> Printed name; <br /> I <br /> IWORKERS' COMPENSATION DECLARATION I hereby 8flimt angor penalty M p®rjury one of the following deciarations: (CHECK ONE) <br /> by Section 3700 of the Labor Code,for the performanconcf thasure twork for wh,or workers,cit rAnaaHon,a6 provides for <br /> pbrmd is issued. <br /> 1 have and wil maintain workena'compensation insurance, as roqu)red by Section 3700 O/the Labor Code, <br /> for the performance of the work,w which this permit Isissued. My workers'compensation insurance <br /> CSrrie�•and D014 numbers are; <br /> ICarrier: n 11 2��[� �I ICl f1 Policy Number: <br /> I certify that ini the perfomtanee of the work for which this permit 13 issued, Is ha11 not RMPJ an <br /> any manner so as to become subject to the workers'compensation .a of Califon t and Orae that N l in <br /> should become subject to the workers•compensation prow of S ion 3700 otthe Leber Cade, I shau <br /> forthwith comply with those Provisions. <br /> Printed Name: __- <br /> WARNINO:FAILURE TO SEOVAE WORKERS'COMPENSATION OOVERAGE <br /> AN EMPLOYER !S UNLAWFUEMPLOYER TO CRIa11NAL PENALTIES AND CML FINES UP TO ONE HUNOR60 THOUS ANDAND DOLLLLAR�SU6)ECT <br /> IN ADDMION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FECS,AMO DAMAOCS A3 <br /> PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE. <br /> AUT .ATIO FOR QR!WR THAN C-57 SIGNING PERMIT APPLICATION <br /> I I' 1 (aign*WM efC-67 lieaneed authorttod r"reeenuMV*), <br /> harabyauth rintnit ) /.rh02/4 r' <br /> to sign this Ssn Joniquill County Waif Permit Applioation an my behelf- I uridaratsM this authorization Is valid for <br /> one(S)year and a Amtled to the work plan dated on the front page of this aPPgoadon. <br /> 8.2wo2 1 Mt <br />