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i)r` <br />Rug 2$ 07''02: <br />Aug. 18, 11007 <br />24p Mitchell Drilling <br />1:16PM Advanced GeoEnvironmental <br />707-444-9049 <br />th 9616 <br />San Joaquin County Environmental Health Department Unit IV Well Parini ApphCatlon supplement <br />JOB ADDRESS' s4s Ease Miner Avenue PERMIT SR#: 5 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Ch&ii 9 (commenting with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License #. 672617 Expiration Date, 6-30-2009 _/_I� <br />Date: 9-28-07 Contracto . Mitch2tik Drilling Environmental <br />Signature: _ Title: President _ <br />Printed name: 6dvard M. Mitchell <br />WORKFRS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following decierotions: (CHECK ONE) <br />_ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />x I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the perfofmance of the work for which this perm t is issued. My workers' compensation Insurance <br />carrier and policy numbers are. <br />Carrier: scste Fk-d <br />Policy Number: 18696D2-07 <br />I certify that in the performance of the work for which this permit is issued. I shall not employ any person in <br />any manner so as to becorne subject to the workers cornDansation laws of California, and agree that if I <br />should become sub'ect to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall <br />forthwith comply wi h th seQ'provisions. <br />Expiration Date: O' IDI O o Signature: <br />Ary, Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' CDMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,001 IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 370E OF THE LABOR CODE, <br />AUT RI TION FOR N C-57 SIGNING PERMIT APPLICATION <br />j,", "! . (signature of"- 67 licensed authorized representative), <br />hereby authorize (print name) 'Robe xc E. MAry <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29.821 MI <br />EHD 19.02401 <br />6122YN <br />P . 1 <br />