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r <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />PERMIT SR#: <br />San Joaquin county Environmental Health Services, unit IV Well Permit Application Supplement <br />JOB AUD44 <br />I he eby affirm that I am licensed under the rovisiorrs�ofnC� ( wyt�i_Mion 7000) of Divi <br />3 of the Business and �1 ��11 <br />Lic #: [�j6i�flicommonaing with Section 7000) of Division <br />Ors <br />3 of the Business and Professions Gods <br />Rnd my license is In full force and effect. <br />Date: <br />CLleans® #: 7 Expiration Date: <br />Sig ature: T �T <br />a 2 _ a Contractor: — /f s�t a G 6�Q-� — <br />Prin ed name: A -4 1\^ --- �J.- _.-. /✓%F I A-. ,12 <br />Date: <br />_ . _ •'•'�• �' -._. <br />Printed came: ��1I�RS'CLARATION <br />by affirm under penalty of ALL THAT APPLY) <br />avend ill mai tai m' forn�r�gtlglfni�8ttbq,®rk�t�lCzib4fibs&�,�cided for <br />i f��iIRSoor o r he performance of the work for which this permit is issued. <br />I ha e a d will maintain a certificate of consent to self -insure for workers' compunaatlon, as provided for by <br />�e�si�i����a��6rf�o�§'�finriRns+nr�afd�asnr�lq�S1fER�f{�(h�'�i� e Labor Cod <br />the ormance of the work for which this permit is issued. My worker ' om <br />q�{ j§yy� rpmmkers' compensation insurancd, as required by f),-gmQn 9�iBt�� Rl��� }t'f t ds, <br />for the pertormance of the work for which this permit ix iHiiudd, My workers' compdnsatlan insurance <br />er:ramer and policy numbers are: Policy Number: <br />Tgld tWet i trf Xe? � `yrs ham �k4or whic i�i�ifsYpet isZN11VI otemploy any person it <br />m er so as to become sub'ect t thweoc�ro{� r�icrhecofINfAttpi�t>�haggtl�@�ifil <br />I ts�t31#>rrt�)�j e�o �ie w��Psp�B?fi�tfrriit4S1 Ci�Qi6rRFathdattier�br��t 1 shat <br />hwifflftMW[If-tn�fh�fi�� � <br />should become sable i tt tf�rP wo ers' cmm�ansatlon orovisions of Section 3700 of the Labor Code, I AhAII <br />forthwith comply with thosgi�n ture <br />Date: 0Y,J)z-01 Signatt <br />r111Lcu Name: <br />Printed Nan <br />NG: FAILURE TO SECURE WORKERS' C <br />AN EIV <br />($100,1 <br />t#Tlt�Al�'s1pi1CmA1R a d x,�,oa�,s <br />PROV�l���i}J;ItA�l�libl�lil8 Di`IIQt� ' <br />pRCIVIDED F01Z IN SECTION 370G OF THF? t.ABC�K C bE. <br />i, MP M #frb)h Y <br />author ze/J l , .>' ,.� /✓itvct-�0 t� c'?� _ - - • , <br />autnorrza.,_. / _ <br />9 P���p tnva myrOrbeffe�tl dr P ti �8���rtr lton i i v alllld for <br />to sign this sign <br />5� n Joaquint +mY� �pRl onza ren ms valid for, <br />to si(1n II tt <br />one (1} Yone f ;' 11 41911040 Y60AWafk dxtQdlme ittvri'C <br />.5-17-20 Q411A.An <br />