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(1 iD / t TF �p09: 49 FAX 916 777 4101 V t4 DRILLING: INC <br />Z 002 <br />San Joaquin County Environrnental Health Services, Unit IV Wetl.Permit Appfifc��ation�S/u_pple2ment <br />i i �? ' r PERMIT SR#`�V O <br />JOB ADDRESS: ? u 1 1 ri ' <br />a.Ll <br />LICENSED CONTRACTORS DECLARATION {LCC)} <br />I hereby affirm that I am licensed under the provisions of ChapLer 9 (coI +mencing with Section 7000) of Divis,'o.n <br />3 of the Business and Pm4essions Crxie and my license is in full force and effect. <br />License #: �-/ Expiration Date: <br />s <br />Date -.1 nu <br />�-- <br />Signature: . <br />64 <br />Printed name: <br />llrn .r r�-) C . <br />- Title: <br />WORKERS'COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declararin:ns (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensatlon, ds provided for by <br />Section 3700 of the Laoor Codi, for the performance of the work for which this permit is Issued. <br />U/ I have and will maintain workers' compensation lnsurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and `policy nxnbers are: / <br />Carrier: _ _ lu pi�� __PolicyNumbor.e,� l -F,g4551-d5 <br />l certify that in the performance of the work for which this permit is issued, ;,shall not employ any person in <br />any mdnnar so as to become subject to the workers' compensation laws of California, and agrees that if I <br />should become sucje^t to the workers' compensation provisions of Section 3700 of the Labor Code. 1 srall <br />forthwith comp',y vrth those provisions. <br />Date: Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 18 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />JN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF'THtr I-ABOR CODE. <br />(C-37 licensed authorized representative), hereby <br />authorize <br />{� [ 1 I j x Cit'j�� L <br />to sign this San JoAquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one ('l) year and is limitad to titre work plan [sated on the front page of this application- <br />V^JO��'- <br />