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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB' 18, RI • I 1 onmental Health Undoes, Unit IpEtrftWimtiteilcatIon Skip pit ent Pa Mk Or <br />J0/3 ADDRESS: (5.06 571-4- PERMIT SR#: 06 2-0 1-6 5/ <br /> <br />Date: <br />Signature: <br />Signature: <br />Printed name: <br />Printed name: <br />Date: <br />I hereby <br />3 of the <br />License <br />Business and Professions Cobe_and In ,/ hr"'^. 1 '' A 'll 4' I hdraby affirm that i -am iicensau unae.r thiaT,rov,s4Rsetrteiate,riSitiAtilltefftent.with $ection 7CCO) of Division <br />#1 of the Business end Professions Code and my license Is in full force and effect. <br /> Expiration Date: <br />Licer-T—le #710 71- ---Z te- I 7-- Expiration 1)eto: <br />Contractor <br />tierar Contractor: lino. ffil <br />/ If I Tiv , <br />..... 7013:11,41,111114147171,7 iiii0kAnr.a. <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />....Arialffiri5 Now <br />&ESAU psi <br />woRwmeEretkfictt-wmoectivawnoN <br />I herebyat Pri siffrileave obacto ri eimatabeffoliEtgirgiyiliedettalow:(64tEaKNILL-rtm-iksweiy) <br />ha e anklimilbrnainIntin-twitiitifiLOXITYkitirtg6MIlitrigfAiitifire8rfWgr. Tgittidth5gaSiefeftV b. <br />Section 31NiEttiofittinlaiddlitalikitaf reffdA4cOgnkiffiiiiiii6WfbrkfibuRarkrfdP(AY6ta t I Wild iSSUdd. <br />asfjpkilicAnAvin.icAtiliMbitizagiiirt 4401,Crog,de <br />for t e pefftV0ailitrIDErffic-WilkItl?ol 2FITis peiliqrgi issued. My workers' compensation insurance <br />carri r an89565iE . Pge,r—r3 ar - i i, <br />frtANCI P (.9 olicy Number I 5-8 t9 Carri+ Carrien'--S Policy Number: <br />I cei-tifv tnat in the performance of the work for which this permit is issued. I shaft riot employ any person in <br />_ I ce ifY-Inh' RrietisamicemfrittleutsituttfctriM0011411IMII*flibiggtctici,PgPfialefifiOlb9rfiNN)n in <br />any anntmocogetszbecgubjectiteolkettialum'weinonstlismig614116-PrAfgterdafbAiP!'411980881h1dire <br />shoi.d bermneittut4ectioAtitittb400415,41410114pensation provisions of Section 3700 of the Labor Code, I shall <br />forth ith comply with those provisions. <br />bate: Signature: _ .....•+........ <br />Date: <br />I ha4eVatwowtfaillOkri#811kAilqiS <br />WARNIN <br />AN EMPL <br />0100,000 <br />PROVIDE <br />WARNING: FAILURE ltikitEIFWVieraFilS COMPEMATION COVERP,QE IS UNLAWFUL, AND SHALL SUDJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />waRKEssrcearmenepieWtOMMOV9fitagMKUIRlihAtc7! <br />novistatimmnanowintanutitIMPFIRPftp TO ONE HUNDRED THOUSAND DOLLARS <br />), IN ADA.J3 Ter TOIHE COSTy01/ExpR;NS;101.,:INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />FOR S T104,1 70pr T Ce? . c • (C-57 lIcnrised authorized representative), heraY <br />,J . z4 Airl eueisl_(0 - 'cense auth orized representative), hereby <br />authorize to sign this San Joaquin County Well Permit Application on my behalf understand this stitheritation is valid (al <br />one 11) year and Is limited to the work plan dated on the front page of this application, <br />to sign this an Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />5-11-20001M! <br />one (1) yeai—and is limited to the work plan dated on the front page of this application. <br />5-17-2000 I MI