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JOB ADDRESS: PERMITS: <br />o <br />Z <br />-Environmental Health Services, Unit IV Well Permit Application Supplement <br />JA utn County u��,�"t <br />JOB ADDRESS. n�ffMA <br />I <br />I hereby affirm that f am li s n t v �(��o �:�g <br />Sj tU 00 of Division 1 <br />3 of the Business to e . 9-1 e IS ,n Force and a jec. <br />i <br />f� of ' (commencing with Section 7000) of Divisiol <br />Etl%ir <br />4j���,a �►r, atn licensed undeC�ii0�1it6 <br />3 of th BLIX <br />u ne.5s and Professions Code and my licrise i in u once an e ect. <br />Cate l , , i _ Contra(= <br />Lrcense 1 �'v ice- ` / <br />Ulf WO onto toC F S C1 F�ATION <br />i 11 <br />Date: h) -(1 � ' <br />jr ^palJtrll����_ <br />I ereb)affir c A' sent to self -insure or-lit1w. <br />IAMire: <br />s2rance, o e I I copy erea ( 3800, Lab.C). / <br />printed narttiie: _ Coma ny ( - 'tet <:a a <br />_xp. Date <br />WORKERS' COM <br />Certified copy is hereby,mished ations: (CHECK ALL THAT APPLY) <br />I� �€�1�f1G�7A`h+���a�dt3hef�Wn'lid' �tmiStlt�gt41��.%�t~f'fJid�rf <br />I f� <br />sation as provided for <br />I have a��1P1�!Vf$1PJfI�f �il ? iis�ued. <br />Section 3700 of the Labor Cade, for the pe ormance f <br />o e <br />hi section need not be ompleted, if the pe miteri a�a�i ��{g qVI� �ge)�dW)Section 3700 of the Labor Codl, <br />^ f� rr�CfiC d drl rbt'^(R�NZ <br />ff' ;cR. I�Spp�P , f�s�sg$�c�" h9`� '��' tienyirt�naeaccso <br />s to rf�3� Riff �fYt1�Et�9� ss ion avis of �alltomia. <br />d <br />carrier an policy numbers are 33 <br />ate Q I* 1 . G- nPri r°� b4r ---- <br />Carney _ <br />OTIC TO. APPUGA��{T:: If, Aa- er m kit c e�(� g@ i��rdfRtli�h95lS a� �a�l�ernPl�7 � on i <br />am -P F&�t%c�inf�f J{�itSY.. :Rem e s jo <br />b R�a�tSfrti ala {�fiO�iifo�rp�,thisl jhjh if 1 <br />e dee d'?�61Skeldso as to become su 1 t �$�ti�'(�b�' <br />- N_ -„ ,ti „Ago�c' �nnQanSation provisions of Section 3700 of the Labor Code. I shy <br />forthwith comply with those provisions 1 //I�-7 <br />/ Signature:_ 62�-'v f� <br />Date: <br />Printed Name: -JA�(��--�/� <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), 1N ADDITION <br />IION TO ON HE COST OF THE COMPABOR coATION ,INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FO <br />(C-57 licensed authorized representative), hereby <br />I - <br />authorize � l C ------ <br />to sign this San Joaquin County Well permit Application on my behalf. 1 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 />b'dn:� � l,J�yp•� � l� l t,c,r� t-i'Li-�-1 I <br />