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09/12/2002 13:07 19166385611 <br /> CASCADE DRILLING INC „ PAGE 02 <br />Y12/2202 13:04 2.09467111C <br /> <br />.3#0 icat- 10,,t <br /> <br />San Joaquin County Environmental Health Depar93JJ t <br />ental Health Department Unit IV Well Permit Application SUpplament <br /> <br />PERMIT SR# <br />JOB ADDRESS: S. TopsJ PERMIT SR*. <br />LIC <br />ifS -431 Coun <br />by affirm that I am licensed under the provisions of r.A.Lantpr c€8,c4,49.43.ittfakoomxpeopbsgmq. on <br />9 44040firentilit'itafesktiMeietadilgetiliterAffees3V1:Ag Rickflekgct. <br />3 ot the Buslnese and Profetaions Code ar flY icon e I <br />Licen0e #: E;05RgRair-bVf4;I - <br />WOWLEW'PeaRtilanIWINDDELI RAPI NN <br /> <br />L Vjrjrioneot ta°Wwingdeclara‘°ns.(CHFC4 ALTHATA_PAPFLY I here AVereofthe follOwingdeclarations: (CHECK <br />ALL <br />LTHATTleAr by <br />I have-fl e. nd <br />will maintain a certcate of emnsent to self-insure tor w . . is issued. oricera' compensation, as pro <br />I. ,./)'''e gm6itoiffiecorbfiC"4193,06tOMpetfter3,41011104tetWPCKAccPpnrZi on , as provided for Ily <br />, <br />&potion 3/U of the Labor Code, for the performance of the work for which-this <br />t p have and will maintain workers' compensation ,nsurance, as requiroDuy ,lec-iiiin52flibitifitiRsiber Code, i <br />I ha e 1,3gItt4viiibiltftiftteintwohtialgsvetilitififfe#W5tic3MriEVIONEIrCiedMurrYewalo9EbykerS5eccrioPnq3(178ti°ollfinthsuer2r‘ambor Cod , <br />for the Rgeorinandcoliidytrigolgertifirliich this piermit is issued. My wattc sef n bin,isInce <br />carrier and poliarmaRke: ()A.. _Q1-\ ix \ licy Number <br />1 Carrier:Po : . '....) <br />Carrlie • <br /> <br /> ..,....... . ..: ..s. eFOliialytNioateimtit is issued. I shall not employ any person in <br />manner so ps to become subject to the worker' compensation laws of Californld, ad ogre* that If I <br />I certify 4419 MO6t9fiblalcte) OfetlWitiWar4( tia m,91109011% Wf fi9t qs.W4°rsiTa? gore Labl or aCrye ' t person emp emplo y ; <br />any mat workers' workers' e ation laws of California, and agree that if I <br />shOuld beco sub'ect t t workers' compen -.1; io rOV of Section 3700 of the Labor CLLo_e_,I ishal <br />forthwidieco ksinature: I <br /> SFPIttlrejrns: V 42-r(X -ChckPin(AA <br />WARNING. FAILURE TO SECUFtE WORKERS COMPENSATION COVERAGe 13 UNLAWFUL, AND SMALL 41.11.1EQT <br />. AN EMPLOYER TO CRIPRIVACIEENSitlIKZ AND CIVIL FINES UP TO ON C HUNDRED THOUSAND DOLLARS <br />' IS100 000.), IN ADDMON TO THE COST OF COIAPENSAT1ON, INTEREST, ATTORNEY'S rEFS, AND DAMA3C5 AS <br /> <br />WARNINt WARM-. :. Li I '•.* ',3' • RPAPE N COVERAGE IS UNLAWFUL, AND SHALL SUBJEC <br />AN EMPLOYER TO C werNAL , ; . ND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), I DDI N T ,0 • "do'. E COST OF COMPENSATION, INTRAiptiiriali:OnfillifinPO@MISM EIRWIftreV5 <br />PROVIDE O E 16.0g _ Alt e, e <br /> <br />th <br />tiut. <br />'I hereby auo t name) . riZa ( 1f , . 04 --, ,2 . C„,..LAik______________. <br />I, . sin jniquel c.ounty well Permit APPitclikin ftlftititgitrf(-VflaritariCennsdedifilalluatuthhorizlndtni ti eci representative), <br />hereby <br />sentaNtirve) <br />hereby airttweriffiiiiiiratiaagretilitoo to the work plan dated on thil front page oft hl* application. <br /> <br />i t <br />to sign thi140421allluin County WRILP <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />JOB-Al -ty <br />1-25-02 / MI <br />I her <br />3 of t <br />A ED CONTRACTORS DEEMA Rckl <br />LICENSED CONTRACTORS D (1Se6P) <br />c...A 952,Y 5 <br />Date: <br /> <br />un erstand this authorization is valid for Am ••• <br /> <br />• <br />