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J AIAIkJ¢' <br />Rpr 04 05 12:30p Mitchell Drilling 707-444 9049 10.1 <br />,CoT� <br />ig g i em--"A <br />San Joaquin County Environmental Health Departrnent Unit IV wcil PermltAppI,cation Supplement <br />JOB AnDRESS: 7 t �,vL�� ('. PERMIT. SR#:' 61;v <br />'00 Yi <br />LICENSED CONTRACTORS DECLARATION Q.913. <br />1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with cection 7000) of Divisior <br />3 of the HJsiness and Professions Code and my license Is in full fine and effact <br />License #. S7 6 7 2 617 Fxpiratlon Date: <br />Date: Contractor. H P Q A-/-! N V f nJ 1/. 60P -JP <br />. <br />Signature: Title: '11n 5 <_ <br />Printed name: PA, -)L Goy fL 6 q;— <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm urger penalty of porjury one of the futluwing declarations. (CHECK ONE) <br />I have and will maintain a Certificate of consent to self -Insure for workers' cornp+:n!-;Won, as provided for <br />by Section 3700 of the Labor Code, for the performance of tha work far which tib; alit is issued. <br />1 have and will mainlain workers' compensation insurance, wt required by Section .700 of be Laoor Code, <br />for the performance of'.he work for which thio permit is issued arty workers' compersatic n insurance <br />carrier and policy numbers are: <br />carr"rer•-1yrlpl4ldStPLL-(ALXi fN5• C0 _Policy Number: o°� oocr Z 7 �J <br />I certify that it the performance ofthe work for which this permit is issued, 1 shall ncI employ Try person In <br />flay manner so as to become sunject to the workers' compensation laws of Cal'dunra, and agree that if I <br />should become subject to the workers' compansalion pfovisiona or Section 3700 of ,he Labor Cole, i shall <br />fortMMth comply with those provisions. <br />Expiration Date: i i G Signature; <br />Printed Nama: 17 ik`J �— 64y'C6 1-- <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL, AND SHALL SJ®JECI <br />AN EMPLOYER TO CRUNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />IN ADDITION TO THE C09T OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3704 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAM C-57 SIGNING PERMIT APPLICATION <br />I, 6 1— (SignatureofC•57Gennsoda0horizedroprosentativel, <br />hereby atuhortze (print narne) <br />to sign this San Joaquin Couaty Well Permit Application on my hetatlf. I understand this authorization Ia valid for <br />nne (t) year and is limited to the work plan dated on thr` front page of tile application. <br />FffD 29.07-001 <br />6=104 <br />