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10/06/2003 10:42 2093345374 <br />tact Q6 03.11:25a Wabne Woodward <br />' 113105120H3 09:58 2093345374 <br />ON <br />WGR SOUTHWEST NOCAL <br />1-707-374-5677 <br />Wc5R SouT�*EST NOCAL <br />PAGE 04 <br />3 <br />PAGE 03 <br />Son Joaquin County Environmental Health Department unit N Well Permit Appikation Supplement <br />JOB ADDRESS. --CA 1- PUN -W—PCA.f41'S @ <br />� . PERMIT $R#. On 530 <br />POA �6;eo,�Or% <br />LICENSED CONTRACTORS DECLARATION [( G <br />1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing v lh Section 7008) of Divisicin <br />a of the Businan wd Professions Code and my license Is in full force and effect. <br />Lk:6n94 #: _ '4 I p[5 '*4 _ apiratkxr tate: _ O S <br />Title: <br />Printod name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of p"ury one of the following declarations: (CHECK ONE) <br />I have W will mak taln a Certificate Of consent to self -insure for workers' compelaation. as provided for <br />by Soctlon 37W of the Labor (coda, for the performance of the work for which this permit is issued. <br />I have and will maintain worker8' compensation insurance, as required by Section 37DO of the Labor Code, <br />for the performance of the work for which this permit is Issued. My workers' compensation Insurance <br />carrier and policy numbers are: [� <br />CAmor: _ 0"d ILC gG Polley Number: <br />I certify that in the performance of'the work for which this permit is l9suad, I shall not employ any person in <br />any manner so as to become subject to the workers' compengation laws of California, land agree that If I <br />should became subject to the workers' cornpensallon provisions of Section 3700 of tha Leber Coda, I shell <br />forthwith comply with those provisions. <br />Expiration <br />Date: A9 <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS, COMPEM$ATION COVERAGE IS UNLAWFUL, AND SffALL SLIRJECT <br />AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOLMAND DOLLARS <br />(9100,000.). IN ADDMN TO THE COST OF COMPENSATION, IN TERE3T, ATTORNEY -5 Y'S f EEt;, AND pAI�AG6g AS <br />PROVIDED FOR IN SECTION 3706 of THF LABOR CODE. <br />AUTHORIZATION FOR D_ _THER THAN "7 SIGNING PERMIT AppLIGATION <br />(slpntitura ofC-V licensed ru%t roprgsentstl"), <br />homby authorize (prim nam <br />to rlpn thic San, Joaqu;n Covntr W04 PamitADpllcatton On my bvhslf. t 011derstaand this <br />autAvrtraRlon Is vend for <br />One (1) year and is limited to the "Kwk pian delay On tho front page of this application. I1 <br />