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AP>r n Jones 5-9451 p • 2 <br />r, <br />6w F oc)e�i76 /,5�32 : <br />San Joaquin Coun y Environmental ekith Services, Unit IV Well Permit Application 0025911::5 2;91!5 supplement <br />l yb 3 LSD aum 4 ff 1 <br />OB ADDRESS: ,vol PERMIT SR# ! G J <br />171 <br />/247 <br />LICENSED CONTRACTORS DECLARATION (LCL) <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />_icense #: <br />l4/ O n 5 Expiration Date: 1 —0 a_ <br />11 — r _ n <br />Date: <br />- (Z 1 Contractor: �i Sc.� Un 0 two -Citi e—i <br />�— Q <br />Signature: Title: _ `' `-� l <br />Printed name: S <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />ance, as <br />equired by <br />on <br />0 of the Labor <br />✓ for the performance tof the work for owhich this permitmpensation s s issued. My�workers' compensation Code, <br />1 have and at on nsurance <br />carrier and policy numbers are: <br />`` UVB,(") Policy Number: <br />Carrier: J ''(( <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 become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall <br />forthwith comply with those provisions. <br />Date: `I �'d� Signature: <br />Printed Name:�� <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 />PDEDFOR <br />$ROV/. IN DSECT ON 3706 OF T I OFHE COMPENSATION, OR CODENTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />1, <br />Pso-k (C-57 licensed authorized representative), hereby <br />authorize <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 />5-17-20001 MI <br />Cchccahcr77 157:1Q TL127/7T /t7n' <br />