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OEC-22-2004 1.7: 10 FROM:PRECISION SAMPLING 510 237 4574 T0:+916e520307 P-2/2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: t �C'l PERMIT SR#-. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provi3ion3 of Chraptcr 9 (commencing with Section 7000) or Droiwon <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License ft �41 3 Q-4— --_ Expiration Data: _J <br /> Dale: i T2 106Contractor; <br /> Signature: Title; <br /> Printed name: keo, WN�� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty or perjury one of the following declarations: (CHECK ONE) <br /> _ I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued <br /> I have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Codc, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers <br /> � <br /> bers are: <br /> <br /> I 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' compensation laws of California, and agree that if I <br /> should become -,ubject to the workers'compensation provisions of Section 3700 or the Labor Code. I hell <br /> forthwith comply with those provisions. <br /> �1,v,� � I <br /> Expiration Datc:jIu! Signature: _'=_ -~ <br /> Printed Name: Gi' �J-vi =------------•------ <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 /> (3100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i 1, �Gjb (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name)__ <br /> to sign this Sari JOnquin county Well Permit Application on my behalf. I understand thin outhorization is valid for <br /> one (1)year and it limited to the work plan dated on the front pays of this application. <br /> 8-29-02/MI <br /> Ir'FIu�e ul-nnI <br /> 6l2Z!Ol <br />