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04/25/2002 00:20 GEOL DRILLING � 19165654356 NO.079 005 San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement JOB ADDRESS' 6-ZGDVJ• AA,-,-miP- l A-T4PERMIT SR#,. LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. License #: ,2-� ' Expiration Date; © - 51-' - Date: (- 2 `t Contractor: Signature: ?-sem; -•�,� •�j��1 Title: 4- WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) _ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will malntaln workers' compensation Insurance, as required by Section 3700 of the Labor Code, or the performance of the work for which this permit is Issued. My workers' compensation insurance carrier and policy numbers are: _-.Z Carrier. "� ". Cie,- wj iJ t C Policy Number: U3 ['� -g2c Va I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: 4- ZA Signature: ; -" - } L—�' l `- • �1 . Printed Name: WARNING: FAILURE'TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,0110.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN 3706 OF THE LABOR CODE. ,r (signature ofC-57 lieonsod authorized reprosontativo), hereby authorize (print name) to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1) year and Is limited to the work plan dated on the front page of this applicatfon- 5-17-2000 / MI