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Licenlettense,c), 5 7/ -4198 EV431**Ifl Date _____NLItOi0 0 7-D tic. Date: Date: 5/2 signaiMPa turar Printed name: Printed name: MPAWItl_09r: Gordon D. Jon '-n, or ion general Manager Title: 209467111E3 AGE STOCKTON PAGE 02( 662 \l‘1‘) San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemert San Joaktgle rirty nvt , I mental He h Department Unit IV Well Permit Application Supplement JOB ADDRESS: ./ v ' 2 ' PERMIT SR# 06 vo JOB ADDRES9:,(. PERMIT SR#: Li c@IFAIg(aglizaff-RJAME.LARITANdtiftP) I here yekrtc9 PC AT P&PrikWsWqrrid*W94I§W;q1-114;AF OswolvemiggioitoSerilianameapp &falai ion 3 of fhe9illiliiirgAr4g5ParactiMiglArP9664W1 grfatilnOWAfiedSsirfnflal form arttleeliwt. 01ORKERSC PENSATION DECLARATION W RKERS' CO PENSATION DECLARATION )/ I hereby affirm under penalty of perjury one of the followLj declarations: (CHECK ALL THAT APPLY) I here y affirm under penalty of perjury one of the folkowina declarations l-WeNnitioRly I have and will maintain a certificate or consent to sarf-insu re e Tor workers *p AMA r by Section 3700 of the Labor.,Code. for the performance. of the work for which this permit is issued. ve ana will maintain a cermicate or consent to self-insure for workers compensation, as provided for S cf;ynl AZ99 Si-fdtVit -(0141b P9•09k PI qifilnOifgitiaglfigo4ritw, wicgOrmlbigisdais3perrott is Use kedor Code, for the performance of the work for Which this permit Is issued. My workers' compensation insurance i ye 424-iwlilfia*E41*-ANOblattfliruompensation insurance, as required by Section 3700 of the Labor Cod-, the performan§pitf4hem0q9a- kilk%619H-Fr8s istmgcl. My wortfpfnRffsation insurance rielCarritilepolicy numbers are.: Policy Number: i certify that in the performance of the work for whpphsaltris issued, I shall not employ any person in any manner so as- to bec.orn-u-subrur..- -t-tottre-actorkers M'mpensatib should become subject to the workers' compens tion.proyisiohs of Section'3700 of the Lab 'Code, I shall I c'ertifygm.6,kparA9 9.4NNfsq, 9,M*61.{4r.k for w* this permit is)ssu Itl', I shall not employ any person any manner so as to become subject to the wyfke/s^ compen0 of iciall,f9krija, nd agree that if I shoeigitiaecomdlEi6036no the worowittorep nsdlkii*09.ie c 1on1713/a) of ' e Labor_aorie_ I sh forthwith comply with those provisions., / ----- I , ' Printed Nernel:/ Gordoh_1).- aenset] ,T ,i- retmtitattev,.."0,er_fs11.4 3„sii., wAR 1 Ls. L RE I o SEC }MK& , ' AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S100,000.), IN ADDITION fhillittottlISTrtir COMPENSATION. INTEREST, ATTORNEY'S FEES, AND DAMAGES AS to sign this San JoaquIn•County ell Permit Application on my behalf. I understand this authorization Is valid for (signature ofC-57 licensed authorized representativ oti one (1) year and Ispnited tp__?* f ,nwci,rk lyan dated on the front page of thi5 application. hereby autbzejprint name) 1-254)2 / \../t it..412, ), to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1) year and is limited to the work plan dated on the front page of this application. 1-25-02 / MI Date: WARNING: FAIIJAE TO SE ERS' AN EMPLOYER TO ($100,00. PROVIDEtRaViagzgal OF PROVIDED FORIN SECTION 3706 OF THE LA OR CODE. MPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJEC CIVIL FINES UP TO ONE HIMRED TH.OUSAND DOLLARS 130Kirff,5frI5ohriring niMiNITUTIntag)AS a kAr OODGELI-AA d Eit,SCI-ELE (916) X3IS3171 dei:Z