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' 9 21 FAX 925 363 7275 TERRA VAC NOR CAL J A 4 0 ✓E�� C2S San Joaquin County Environmental Hialth Department Unit IV Well Permit Application Supplement JOB ADDRESS: Z ( 03 (o v -V4 00, 61 d , PERMIT SR#: LICENSED CONTRACTORS DECLARATION (LCD) 2006 I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. License#: C57 #552198 Expiration Date: 6/30/05 Date: Oct. 17 03 tractor: Western Strata Exploration, Inc. Signature: LIZ -,- Title: President Printed name: Svivie Jensem WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) _ I have and will maintain a certificate of consent to self4nsure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. _ I have and will maintain workers' compensation insures, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: Winn & CO Policy Number: 1569784-03 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions Zon 3700 of the Labor Code, I shallforthwith comply with those provisions. Date: Oct. 17, 2003 Signature: Printed Name: Sylvie Jensen WARNING: FAILURE TO SECURE WORKERS' COMPENaATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CiViL NES UP TO ONE HUNUREU THOUSAND DOLLARS ($100,000.j, IN ADDITION TO THE COST OF COMPE TION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR ODE. AUTHORIZATION FOR hereby authorize (print to sign this San Joaquin one (1) year and Is 8-29-021 MI HAN C-57 SIGNING PERMIT APPLICATION ofC-67 licensed authorized representativq), Penult Application on my behalf. I understand this authorization Is valid for the work plan dated on the front page of this application.