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PERMIT SR#: <br />uoneogdde alto io abed uoij eq; uo polyp ueld4JOM 641 01 <br />, 0 Acie:194 <br />EpuaJg paluod <br />:Kea 01 °Hie <br />JOB ADDRESS: <br />.re'i • A <br />oj mien ef uonezprityintreini jicueq Aui uo uonemddv mulod Hem kunoo ufnbeor ueg flu; UN; 0) <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplemen <br />IVd I 000Z-L1,1 <br />c; <br />,Veurolk d oft! I i,sofiftkoli 614140 timninditill.44-0Qtrapieragl4REgiSTIgeEttipcopticri-Pi.01)510? OT ebusiness and Professions Code and my license is in full force and effect. <br />License #: '‘,19192 HAW 3H1 JO NU NO11.039 NI 210i GaltA0Hel <br />SV S3OVWVO ONV 'S33A SAAN)J01.1.V ‘J.S3b13.1.N11,10fresladVM€I0_,12.0.3_3141-41 Nowaav NI l000`0010 <br />Date: SHY1100 ONVS110Hi C13401VAR19 01. cif) SaNIA WOO GNV S3L1.1VrOci 1VNIINI80 01 )43A01c11113 NV <br />133r1IGTITIMS-INVIIII-AM"FINfIVTVMA- .0.311011.VS113.0100 iSk13}ItIOM 38 non oi jyyj :ONINVVM <br />signature: <br />WORKERS' C <br />Hells I 'aPoO ioqe el-1110 OGLE uoPas JOsuo <br />I herptwiafftlftrrikAlr'061=RtfafiFiewl/win <br />ui uosied Aue Aoldwe iou Heys 'pOnsSf sI Ifu.0 <br />- . Aldwoo tookupoi PENSATION mud uofiesuadwoo Wqns awooaq pinoqs <br />wis,,siaRor§aqm parqns awooaq 01 68 os lauuew Aue <br />OWildie>.War16:aigdraciiSoAA41-uTithomaiap tvy- <br /> <br />I have and will iri4ay„ CPAe W641 WI ti" u &PgOLIFYfflitHlijg'it irlfariti401 *tiQ01046041PK41.1efil FS 4r,code <br /> <br />48 cift44-13o Oil 1ti.9i1A iter 6ope:freti alto:IWO 409 at9144WettleaMS116AVIlf ?Mr-6 n'Cg '91384[1'69SM •Mil • ey numbers are: <br />.panssi pulled S!114 43114M JOI 410M O(a J aoueiwoped 9141 101'eP00 INIT1 041 0 OOLC uoticceS <br />496fiOSi:)Int-tir1 qinileSUadWOO ,SJaVOMioj ainsuf-flp%ptylpfAcljepleDUlliab e uieumew hIM NB 9At I — <br />I have and will maintain a rertifirate.olLAN,mridiiioss i suie for sivgrilicf.,6§cranwetiTedianyaPfit4Oraed 'or by <br />Section 3700 of thOrdSoiti-S0QQr'fFe1Tie-rform'ance of the work for: which this permit is issued. <br />siaquInu Ao!iod pue Japeo <br />uo funDad faieued Japtin u.uwe itqcoe4 certifrigaVriViti.pgiv-Nagnicof tt440WANINPAiltv9lifkaWr rs issued, shall not employ any perscpn in <br />any manner so as to become subject to the workers' compensatiorj.ly„Lolf California, and agree that I should become subject t(Ntt)PIAMIV1103451ititettiMSN41:5VQ04HM.Ti 3700 of the Labor Code, I t hall <br />forthwith comply with those provisions. :OWBU PB)UPd pJojmpi vpuaig <br />Date: minveuBig <br />JO <br />Signature: <br />euew suoTTeiaadO :era <br />Dui PrtiatNiita u tea <br />WARNING: FAILURE TO SECURE COVERAGE k woRKFRs',g <br />I N EMPLOYER TO CRIS1ittAILIDIES AN115/Mtit P TO ONE HUNMAIHOh , SAND DOLLARS <br />945k-jID SRAPSISII2IBJECT <br />$100,000.), IN ADDITION TO THE COST OF COM uu PROVIDED FOR IN SECTION 370.081taTillf <br />PEN WOMAN 8 asuu <br /> <br /> AS lttWolig5rRBOW5cFPFK6SicaltsffEMASIBIS <br />UOISIAKI WOOL UOIPOS 111Wt 6upu0wwoo 6 104 ego Jo suo!svoid ay) Japun pasuaoq we leg) tingle Aqaiaq <br />:0113a <br />iallNelYageNaVel:fresentative), here ay <br />Y9ingEPEafiggAMSAYsq9E1 or to sig-R4Vetn-do ,§elilitaiMpplicti.tigson*aeh <br />one °War.] ANA WtRIN WffibEVVAIViciRdnthgetwubsigteeRtintwmoffetWafq unoo ulnbeor ueg <br />5-17-2000 / MI 1 4 -o-i-a-(n -Y12 5 <br />d ELLB-S917- 0 cix3 um-i-4oads en! I