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- -� - 2nQ-465-8773 <br />`i nos Sp'rr trum Exp. <br />:i <br />i' San Joaquin County Environmental Health Services, Unit IV Wei# <br />J <br />Rut County Environmental Hesith Services, UnitIVWell Permit <br />:Am it p Hca %r <br />PERMIT t�. n� 3D <br />JOB ADDRESS: <br />LICENSED CONTRACTORSS EE <br />LICENSED CONTRACTOR�-D.�►W) <br />I h reby affirm that I am licensed under the provisions of Cha ter 3o the Businesh�I hereby rtn license is In �,gg" <br />Lic rr§p" Business and Professions Code and my <br />EXpi04/30/2003 <br />License C57# 512268 Ezp�a�o�tt�ate <br />Dat . Cc tractor: Fxnl oration, Inc. <br />ppate: Contra or <br />Sig ature: TitleTitle; Operations Manager <br />S��nature• <br />Prin a ame: <br />Printed name: RK <br />WO W��F�ErR�S�l�3����I�iQ'®f�O�DN <br />I her by affirm under penalty of per�y �o ti y� THAT APPLY) <br />I hereW affirm under pena'Ity I peri � 161 +� . � '&L� AT APPLY) <br />I have and will mai tair erti };pG�Ccom psation, as provided for y <br />ge`}{ rz►;3�r� in �i�?l�irlf�i�� m� tfti�i iflsRl>Ad for by <br />ction 37DOo(' j; of �r��" �41W Q�h is permit is issued. <br />I ave and will m i r� r it b Section 3700 of the Labor Cod <br />f r �r ale INStp§F AW � r i4 t19r�i I MW@e, <br />c rrier °'f`' t�fatid. or ers compensation insurance <br />cam yrs are: <br />Ca ierV,_ I'c Number:3BG03575800 <br />���Te� <br />American Motorist psi rQ� er: <br />mlit is issued, I shall not employ any n in <br />I ertif t r ich thig Re if I <br />y {i�P�rf fow Fi�R t ch this e Elb�,l Ce®ii1 1Pf)f�y3@9 <br />shYma uld g)og��tpteo0jeet �l 9r 't dfl_WCP �cf f[�i AIR" �i i shall <br />3otl�ectdCrt;�^i@fla �ii provisi ns f Section 3700 of the Labor Code, I shall <br />fo hwitq(h 0I9oIsdtptb9WCpr ?visions. <br />i <br />i <br />Date: S §Lgnature: <br />PrintedPqyft� Name' Brenda C wfor BJ CT <br />WARN] �}/►>tEfi�tj.� RS' COMPENSATION COY THOUSAND DOLLARS <br />AN EM LImPfEMRt�i 1 R���IOIDF� /�R�d®� �, l IA�IAIA�DJ aer-S S <br />j A WAft) i�� �160-T14� AND DOLLARS <br />i ($100,0 �I �WUA6(111�QPW4EREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVID E LABOR CODE. <br />.'�{';• <br />`Brenda Crawford of Spectrum Explor.ilsignatureofC-57IIcnensed thorized <br />represen <br />�y.ive), <br />r a If liceni64Ztho i 6r <br />horiz hereby authorize (print name) <br />,. 'hghall I tinderstand this authorization Is valid for <br />" pn <br />a$& Joaquin CountyWell Penn1,1301"' <br />d :Sign t i 5; quin County Well Permit Application on m b jii plii6a�othorization is valid for <br />,v <br />i e 1 g'�e 4��'1'r end le limited to the work plan dated on they iii plate <br />O y a : n united to the work plan dated on the front page of this application. <br />-200 <br />7-20001 MI <br />,i k1 Z <br />