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Jul 07 04 09:54a <br />67/ai/2b04 08:44 2094671118 <br />916-85P-95 9 <br />AGE STOCKTON <br />� 1 <br />A2/ 02 <br />F—s an <br />Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB <br />environmental Health De intment Unit{E1��I�rr�1 I+cat,on 5upplertwznt <br />�,} <br />•" l� ✓� Ul PERMIT SR#:` <br />JOB ADDRESS: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />LICENSED CONTRACTORS DECLARATION (L.M) <br />I heret <br />y affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Divis <br />on <br />3 of th <br />,s { � gf s [�( ��pf�, ( Is mhf *Af)9cjtmm0h .withS +pion 7000) of OMsic n <br />3 of the Business and Professions Code and my license is in full farce and <br />Licens <br />#: Expiration Date: 1 <br />License ?x Expiration Date: <br />Date: <br />Cont�aoc o,: <br />a e: <br />Signa <br />- Tim <br />Printe <br />}%per n rine: <br />WOFk��8R'bTE 1ft <br />I hereb <br />oo full ginM dlClaTtions: ,(, � K 014 <br />-Ay aYFlrrnAnd9r1t lt�� jfupryrlurye0r of To"] <br />fir unC7er eI� I �ta r n o he owing ec aratlons: �l+ <br />I hwm and will maintain a certmcate of ccnsemt to EeXintntire fpr workars' cempe=00n, as provided for <br />_ I h�ve <br />ayiiraf3trr>$[tittEGbjrsiseer'setfgit�su�tdtF®dvf�rtrtA�C10 00ovided for <br />byiS��tion <br />3700 of the Labor Code, for the performance of the work for which this p@rml Is issues <br />ar.d wilt maintain wohers' cempensa"'.ofl msuralfCa, a= ryquir@d by 3ecticni 3i'QO Ot :t1e Lol�et Ccdc . <br />I have <br />a 6�M1rI VhWil rs ' i 'Ir ' 'C��5 2 �'r c� y�ec i'cn of"tie a�or Code, <br />for <br />ca <br />the ppb °d�f��' v�rorfZ orl�vvhicf� th psLmit is issued. My workers' m ensatio nsurance <br />rier ty AWlicy uplbe g� <br />Ca <br />rier: I ccrtif / that in the p,!rferrlance of Thom waA ser+idth hiAlavrbitfs Issued, I shall not arnplcy any perscn ui <br />any rnanner so as to he=me subject to the workarz' compensation laws 4f Calftmia, 3nd agree t1lat <br />i c <br />rtify *, 1 �1R 8fR ri�@�ft�t r d c 'S fiit�it'1�11s� ' ftt'r� �� '1 �i0a414�a `2�ttl ry��l�y'a 'on <br />n <br />an <br />1 mar1Krl"'S" 1ffTF% $r 0 FNI`89e workers' compensation laws of California, and agree that if I <br />s <br />til¢ ' art jjeZI rk� ��ensation provisions of Section 3700 of the Labor Code, I shall <br />fo <br />l -W comp�y wit pro is ions. <br />Printed Name: <br />Expire <br />ion Date: Signature: <br />WARNING; FAILURE TO SECURE W0RKFRs�c MPElel i <br />AN EMPLOYER TO CRtMrL TIES AND CIVIL FtNE5 UP TO ONE HUNDRED THOUSAND DOLLARS <br />IN ADOITN 1F <br />($100,000_ IO <br />PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE. <br />WARNING: <br />FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER <br />JW111100MOAFRO SIZIR _ LTf# M aP liilibi l;0$$'�S <br />($100,0)0.), <br />IN ITIOf�T;VTH E) T)OF C�Q�SATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES A <br />PROVI <br />FDF ttl��}}�g37 �QT����?_L(q( ODE. ] (siora■tury o/NC-57 Ilcrmvd authorized representAtM ), <br />to sign this San Joaquin County Well Psrmit Appilcatlon on my behalf. I understand this vutnortxwan Is valid for <br />I, <br />(signature ofC-57 licgensed authorized representative), <br />na year an m n nt pags of thisl appgcation. <br />herebyMti�0g6print <br />name) <br />a <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1)fyaW.®1&js limited to the work plan dated on the front page of this application. <br />913tY2002 <br />8-29-02 / MI <br />EHD 29-02-001 <br />9/30/2002 <br />