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San Joaquin County Environmental Health Service*, Unit iNf Well Permit Application Supplement <br />iliNACk••VI04_, <br />El ADDRESS: -5-Tir-gliatAK - PERMIT SR#: <br />srfrttAi Cia ALT <br />LICENSED CONTRACTORS DECLARATION (LCI2iE pEptivi;\s'E'R`i NviUt = <br />ICES <br />hereby affirm that I am licensed under the provons of Chapter 9 (commencing with &elan 1000) Of (Arleen <br />3 of the Business arid Professions Code and my license is in full force and effect. <br />License*: 6 5 Ti Expiration Date: I i / c f <br />Date: 2-V/ 0 1 Contractor: z ' /4(1 <br />Signature: Sc & .1' t4,1c.".y...1 <br />Printed name: he- <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penaltyr operry one of the tollowing declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certcate of consent to soli-insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work fat which this permit is issued. <br />k/ 1 have and OP maintain woncens' compensation insurance, as required by Secgion 3700 of the Labor Code, <br />far the performance of the work for which this permit is issued. My workersr compensation insurance <br />I certify that In the performance of the work for *bid, this permit is Issued. I shall not employ any person in <br />any manner so as to become subject to t le workers' compensation laws of California, and agree that If <br />should becocrie subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith corripty with those prolitsions. <br />Date: Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER -ID csibugAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />0100,000.1 IN ADDMON To THE cour OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />Pnavtoen Fan IN SECTION 37ne OF THE LABOR CODE. <br /> (sbrature at0.57 licensed authorized representative), <br />he runittinza Coda name) 45 1:1-c ‘e. k Si. 06 <br />to sign this San Joaquin County Well Permit Appiicartion on my hz!=i!. ! modem:Ism' this authorization Is valid for <br />one (1) year end is Hated to thy work plan dated an the freed My of gilt *McMinn- <br />5-17-21100 /1141 <br />center and plicy numbers are; <br />Crier: e-c4-1 •-riu Q Folksy Number: I 67 R3-1 Z-3 31r — 0/ 0 <br />DEC-14-2001 11:55 FROM PRECISION SAMPLING <br />TO <br />1916E610430 P.01