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OG/19/2003 09:59 19166385611 CASCADE DPILLING INC <br />e6! a 8/20;3 17:,11 209467111ts <br />I <br />PAGE 0"' <br />San Joaquin County Environmental Health Department Unit IV Well Permit Applic ' <br />JO AIWRE@ ^ FQUn'ty Environmental Health Uepartirnent Unit IV Well Permit Applitalttan �uppkrnottt <br />PERMIT SR : <br />I JOB ADDRESSt 1J�I � c ; I.� PERMIT 3R#: ^--- <br />��qq ��QQRRgg DF. <br />L!(�.LICENS�ED CONTRACTORS D�CL�' _� <br />i her by affirm that I a� licensed. under the rovik%iso� � ( t; glwii�,bB�sti�Aflt119b�t 'Suis <br />3 of t a trdusb�dl 'tafiNl ,Msu�b ' i 'r tct. <br />3 of ttie Business 113 Pro s <br />Licen a #: ti41rl Date: <br />t.� <br />Date:J 0 3 o r,.0,� �%_-=-r i C, <br />Signait p lure: Tine: <br />Print��: <br />name: � C� <br />WORKERS' CQMPENSATION I3ECLA <br />1 WORKERS' COMPENSATION DECLARATIQp�N1 <br />I h retry of km una or penalty of perjury one of the foliowing.deelerabons, (CHECK ONE) <br />I hereby affirm under penalty of perjury one of the followin� eclar �� provided for <br />! Fieve end wN'� maintain a eertmate of consent to s f�nsure��� <br />r the ria rice of the work for which this permit is issumo. <br />I gave t1 g914Fia3 iAf�IR&R c�nsen o se'� -insure for workers' compensation asp ovi ed for <br />bye s t,�n e 00 of. r f � tf a rongdldd► fit A�is� i$4 i �a e, <br />ave and wl � <br />or the rf , ante of the Work for which this per -nil is !$$tied. My workers' comp! $ n <br />I have j�(}I� . rw mpensation insurance, as required by Section 3700 of the Lobo Cod <br />fo the perform$ b t�worrhi h termit is su d. M oro eatrtuban ec@I-rier rjbpii ,f>ai,11 V1 � � Po�tsoy huin&- <br />Catrier: i certitY that in the person' =x4 of the work for y�ish the �r[11it is SsueQ. I $halt not ernpioy ony person in <br />.k�1'tx.A44l i i�6n Sawa of Ulifemia, and agree thst if I <br />ion <br />any manner 5w as w vesw,-c --PvwJ"•, •• •• ••_,,._ _ <br />�u,c�e,l, to the workers' a mpvnsation provisions of 5 divn 37D0 d e Labor <br />I certify �� �k for which this per is is ed, I shall not employ any person i <br />an manne so a be subject to the work s' om atio ws alifornia, and agree that if I <br />sh tdq�eL- 1 z.`t fa work�s i 3Y1%0X0 Ulf tL11h1U5,M56-r o e, I shal <br />for. hwit mply with those provisions. Ccx- C CA D VV\ <br />Printer! Name' <br />Datenat��r� IJfNI AYiFUL. ANo at/A11 <br />WARNING; FAILUR9 TO W-C-U'SUBJECT <br />WDIUCE <br />AN EJAPLOYER TO rRMI1NAL PFNALTI �' AND CIVIL FIN1r$ UP To ONE HUNDRED <br />T"MUARV Vu - <br />($100,000.), IN ADDI, CNRor*Wd6wn@F COWENSATION, INTERtr$T, ATTORNEY'$ PEE3, AND DAMAGES -AS <br />PKCMDED FOR IN 4ECTION 3706 OF TME LAWM <br />AN EMPLOYER URE 741k O SE UR �QN � D US ND DOLLARS <br />�UBJEC <br />($100,00.), lklADDI TI T OST F COMPENSATION, INTEREg T A <br />PROVID F TRIE T4 of <br />�i IVTC H1'1VIV � T119Afor <br />to sign M,rn Ban Jo�vin county Well Fsrmlt Applicatlon on my betteif. I undorstand T AQP I I i <br />(Siam RtaXa5AkwMwEd authorized reDresentativel_ <br />hereby �ujtl',Wint n <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />i <br />one (1) year and is limited t� the work plan dated on the front page of this applic'htion. <br />8-29-02 / MI <br />