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' <br />Date: <br />PrintegrrWide?am <br /> Mitre ficheral Manager <br />sen, Jr. <br />2 2834W1118 AGE SIOCKIUN PAGE 02/q <br />San Joaquin County Environmental Health Department Unit IV Well Permit A <br />Torment& Health epartment Unit 1V Well Permit Applicati c7) <br />JOEI cr. PERMIT $R#b <br />JOB ADDRESfl5 < PERMIT STIP: <br />I her <br />3 of t <br />Licen <br />W(ORKERS' COMPENSATION DECLARATION <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I here3y affirm under penalty of perjury one of the following declarations' (CHECK ALL THAT A.PPLY1 <br />have and will maintain a certificate of consent to serinsure for workers compensa as orovioeu fur by <br />have §MERkrillPAYSiRIAqi EOrrtBg?er8iTW8rPseginnana of the work for N,vhicfl this permit is issued. <br />I o s -insure tor workers coMpensation, as provided for by <br />Sc4ipnTaVar11 lig AAPaiRgptv-AwgRipmworWPFaiiMitfPcslalli§riaNTOtifellst14%%tetdar Code, <br />for the oerforrnan.ce of the work for which this permit Is issued. My workers' compensation insurance <br />X I have ebAgwroothwiliwor.grg.ccompensation insurance, as required by Section 3700 of the Labor Code, <br />for the performaauf tlronagun/MhitliRmipuied. My wodied—s'ff9FaBrsation insurance <br />crrierAi rpolicy numebers'e: 'Tolley Number: -L)Uj <br />Car i4:, I certify that in the performance of the work for yksitpaitslymbs issued, I shall not employ any person in <br />any manner so as to become subject to me workers' ciompensalion Idwa of California, and agree thut if 1 <br />X I ertify661•PAOTPMMA*Val8fAitqqiVf8Mr01-Yrt)-11FOR111? ti'lM Fga I? fn 1 tol? gb <br />r <br />y oadney. p <br />l shall <br />ers o <br />any marr9FitbeV)Willd)1Abott-igsELVISKITOsthe workefS' cornpen effio -1,•dr)S. of Cali • ni,a nd agree that . <br />sh Wt;iecornpippj1944jo theworOdA'AwperiSation o _.,e.c.titia-3. II OP. e Labor Code, I <br />fort wirfi comply with th-ose provisions. /— /------,./ <br />PrIntud Name:., rt . GOI7jo.D .. ,tensen <br />Date: Signature: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL ULM EC <br />ND CIVIL Fl ES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(V 00,000.), N ADDITION Prit 'COMPENS lION. INTEREST, ATTORNEY'S FEER-, AND CIAMAGFStAS <br />IIIW.A? 'MEE <br />LOVER T <br />.), A <br />N NS 0 THE LABOR C E. ' <br />AL4'IES AND V FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />IN B CO <br />ORKERS' COMP SATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />NSATIO TCRESTPAT-VORNEEprogfA341;40/12PETIVMAPAIS)AS <br />I ED FOR IN SECTION <br />hereby authorize (pri. narna) <br />,t6"sign this San Joaquin County Vliell Permit Application on my behalf. I wools/stand this authorization Is valid for <br /> (srgnature otC-57 licensed authorized representative), <br />one (1) year arid Is limited -to fps work plan dated ,bn thertront qgge of this application. <br />hereby authorize (print name) / to,,,/, /// / V \ V .i / fC '- <br />1-25-02/ MI <br />to sign this San sii)aquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />1-25-02 / MI <br />L Itgrc II <br />16 <br />IW <br />t <br />..2) <br />b affirm at k$V, OW4ciiilkie111Pd°15RARR§Stf6t*P4P0 )c(SolilgliefaOlVt/WilbcSecfrOb0MayilifiEfivis ion <br />(99RPURriliN 4"rieW)FP.P(t(iitPgkviVikfgi§@iiPlkilfifitiltdOfCeratIcIfteftct. <br />stignqn-ii j-9 '&2198 Expirultionlatft • 0 <br />AN EMPLOYER TO CRIMI <br />Ed 1317SO -ELE (9 .16) X31S311 dai:ao ao i7e Rew