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\\/tl,t1 ,y authorize <br />my behalf. I understand this authorization is valid for <br />(C-57 I;censed <br />ch <br />horized representative), hereby <br />V\Vi <br />15:31 FAX 916 777 4101 i7 W DRILLING INC Z002 <br />JOB ADDRESS: PERMIT#: <br />San Joaquin County Environmental Health <br />4 <br />„Ige, ADDRESS: <br />I hereby affirm that I <br />3 cr the Business and-:' <br />Li8drilsvioy affirm that I am licensed undrigpiggt}oriNftes of Chapter 9 (commencing <br />3 of the Business and Professions CDde and my license is In full force and effect. <br />Dat iCE113C #: 17,9o9oil Contractor Lxpi. alort pet /00/ <br />I Nigti 9.fa4n e <br />Ex. Date WORKtRa3fslIAPPNSATirmi nFci ARATICIN <br />46-64rtiftfillicalpiris..iheotOetftornisrjury one of the following declarations: (CHECK ALL. THAT APPLY) <br />p ertified copy is filed with the County Building Inspection Division <br />I have and will maintain a certificate of consent to self-insure for workers compensation, as provided for by <br />Setitti"Z-f*R-TE/-&3 trXtql.WridifFlik/t9thrclbrIEVAtEit'Vti5VPrE titrVICtgORAINCSJ- <br />IA 0..no, <br />;_ - lootiropflo e in with I ) 7000of Division <br />rfices, Unit IV Well Permit Application Supple.rpent <br />oozsoig <br />TO RS D EEC tuAtiVerii) hr co .2 0 <br />w;th SoctiQn 7000) of Urvision <br />I <br /> <br />Dale. d- WORKERSACKOVI,F5biSkFild,glyralatFCATIO N <br />112 <br /> <br />I hii9aSthwii crtt6eftt cnt to coif insurc, or-gt <br />- iT 7-4recifAir,(3 , Lab.C). <br />c <br />as <br />Da e <br />I Certii7 <br />NOTICE ErTY R-0715L <br />Co <br />be <br />rripenr, <br />deem g <br />I have and will maintain workers ' compensation insurance, as re_quired by Section 3700 of the Labor Code. <br />is sectl,artti*?Skil04.1tRgliAllig 48-OR WMOefictf-tir34,0951diiiikg@EP. (MillWcRicgs)compensation insurance <br />rtify +,4,Atchbth@r-ROaliAjawkit4kog Aftiv for which this permit is issued, I shall not employ any person in any manner so <br />o become sulti tib the erl Compensation. Laws of California. <br />Carrier: 1 Policy Number: jUk/C -54/5E5g-6 <br />Applicant <br />that In the performance of the work for which this permit is issued, 1 shall not emp{oy any person in <br />ritrAprliftikgp moytifftgiN4rfrati.refoestioriwcpt)gt-/Aye%it,bwtfolw*tr-it4rs, <br />Facol* srvtisOrI6ipfflagfifetliFAiitRgiffilf 9.At Ecdaci W:Fas98Niedr RI- ;Cii.Arit 14-ra41. <br />&a.mp y <br /> <br />witfl tnose provision. <br />Date: Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />to sign this San Joaquin County Well Permit Application <br />one (1) year and. is limited to the work plan dated on the front pagp of this application. <br />E 'd VJOelA IrTVVG , 2I 6Ba .