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San Joaquin County Environmental Health Serviette, Unit IV Well Permit Application Swamis/moat eDoz.-T6 <br />JOB ADDRESS: Z3.4%P S:249 agra9PERMIT SR*: COO 76_02 <br />I hereby affirm that I am licensed uncier 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 forte and effect <br />• <br />License IP, CP-r 7 hirS'Sfig.,r— Expiration Date; <br />5 R roetwirero k 007--(0 1/ <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />ContractoAnW 14../64;iy_4 <br />fimat, _ TitiegattaiA ltarefate <br />ggielloate" <br />Date: <br />Signature: <br />Printed name: eh!, <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />SI hake 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 ie Issued. <br />I have and wIN maintain workers' cornoeneeitiOn Insurance, as required by Section 3700 of the Labor Code, <br />ion the performance of the work for which INS permit IS issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />CarrierfikfC r Aifhef <br />I certify that in the performance of the work for which this permit is Issued, I shall not employ arty person in <br />any manner so as to become aubject to the workers compensation laws of California, and agree that if <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I Eihall <br />forthwith comply votth those provisions. <br />Data: zio/z /of _ Signature: <br />Printed Name: <br />WARNING: FAILURE 10SECURE WORKeRs• COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL suancr <br />AN EmPLovER To CRIMINAL PENALTIES AND CPAL FINES LIP TO ONE HUNDRED THOUSAND DOLLARS <br />(6100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEResi, ATTORNEY'S FEES, AND DAMAGES AS <br />PROvIDEP FOR IN SECTION 3706 OF The LABOR GoDE <br />I C-#1,*r. sip4e fliet - <br />hereby authorize (prim name) <br />to sign this SIR Jealipgr! County Well Permit Application on my behalf. I understand this authorization is valid tor <br />one (I) year and is limited to the work plan dated on the front page of this application. <br />5.17.20eo / MI <br />Polley Number: We. airePAr6 0 <br />-.•••••••". <br /> (signature otr-47 !Imposed authorised repreeernativo, <br />qc 0:39 FAX 1 916 861 0430 SECOR-SACRAMENTO Z002 <br />Sent By: Gregg Drilling & Testing, Inc.; 925 313 0302; Oct-2-01 10:22; -age 2/2 <br /> <br />VuL LOI,aV scum-SACRAMENTO Z002