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) di Altrialsed San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement JOB ADDRESS: Fofi, S±-6 c.,--60 rt. PERMIT SR4t: 00 3 2 5 30 LICENSED CONTRACTORS DECLARATION (17CD) I hereby affirm that I am licensed under the provisions al Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and affect. License a: 36 3 F--? Expiration Date: I / 3 4/1:>%1 Date: /I- 63 Contractor: ft^t, 4., II) 4) 40\ ..1.7^0 . Signature: Title: -,41 Sy 4i Printed name: WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) I have and will maintain a certificate of consent to ea-Insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. )eI have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued, My workers' compensation insurance carrier and policy numben3 are: 4i-4.4ne-v-,is lic ,ikikn sz.-, g",z Polley Number: Wci 431I 0 -7 7-335' 17— I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to became subject to the workers' compensation laws of California, and agree that II should become Subject to the workers' compensation provisions of Seaton 3700 Of the Labor Code, I shall forthwith comply with those provisions. I L/63 Printed Name: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000.), IN ADDMON TO THE COST or COMPENSATION, INTEREST, ATTORNEY'S PEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE_ UTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION hereby authorize (print name) M - ct e ocii".•41111111. IMMINIMPiewitegro. UP sign this San Joaquin County Well Permit Application Ler my behalf. I understand this authorization la valid for one (1) year and Is limited to the work plan dated on the front pee tUi3 application. 3.294121 Date: Signerture: Nr) (denature otC-67 'loan:sad authorized repreeerrhinre), je YL. 6:45 GEOMATRIX FRESNO 559 264 7431 P.03/04 nwamIJA yTNImunmn Cic!sT CrAM7 -T7 7171/7P'A T7I'L f7c17 acc