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10/22/08 11:39AN All Well Abandonment 530.644.1439 p.03 <br /> Received Fax: 10/21/08 09:02AN Station: All Well Abandonment - p.03 _ <br /> San Joaquin County t~nviranmentat Health Department llnit IV Well Permit Application Supplement <br /> JOB ADDRESS: 2 2 Z E . W E S E R AYE, _ PERMIT SRO: <br /> 5ToGkTQU <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapi it 9(commencing with Section 7000)of Division <br /> 3 of the 130ness(a(nnd Professions Code and my license Is in 101 force and effect. <br /> License#; 'fi ISS�/ Expiration:)ate; < c / ,Off <br /> Date: l� - trac Zg-1ZZyell ���'�/"CCLa` � <br /> Signator '. Title: 14 <br /> Printed name: S� <br /> WORKERS' COMPENSATIO14 DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dei larations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to sett-Insure for workers'compensation, as provided for <br /> by SeOon 3700 of the tabor Code,for the performance a the work for which this permit is issued. <br /> I have and will maintain workers'compensabon insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is iss ied_ My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. 5-1- Z r/r Policy t lumber: I'-7= "",2rYJ ,Z <br /> I certify that in the performance of the work for which this I:ermit Is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers'coml ensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions. -- <br /> Expiratlon Date: b V Signature: `Y <br /> PHm <br /> nted ae:_ ._.a.?1I (2- <br /> INARNINa:FAILURE TO SECURE WORKERS'COMPENSATION f-:OVERAGE tS UNLAWFUL,AND SHALL SU9JECT <br /> AN EMPLOYER TO CRIM114AL PENALTIES AND CIVIL FINES UP"to ONE HUNDRED THOUSMD DOLLARS <br /> 1$100,000.� N ADDITION TO THE COST OF COMPENSATION,IN-EREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> qu ION FOR O H la SIGNING PERMIT APPLICATION <br /> (aly',Inature ofC•67licensed authorized representative), <br /> hereby authorize(print name) <br /> L� <br /> to sign this San Joaquin County VWI Pemit Appileatron on my 1.ahalf. I understand this authorizatton Is valid for <br /> one;11 year and Is limited to the work plan dined on the front paP:p of this application. <br /> E 8.29.02!Iltl <br /> EHD 29-02-ODI <br /> 6,22M <br />