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License #: <br />Date: <br />Sig nature: <br />printed name: <br />MAY 02 2003 EI:SSAM HF ASERJET 3200 <br />May-01-03 03:04pm From-DROWN AND CAJWELL 316 635 6605 T-061 P0031003 F-609 <br />P.3 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application <br />Supplement <br />JOB ADDRESS:. j112.._/±6 <br />_ PERMIT $R#:_a_a_laiL <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisiOns of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license Is In full force and effect. <br />0 Expiration Date: _ 0/3 / /14 <br />Conuactsr: rinte:719, 60 <br />ltrA0 1(4. <br />a)ce__ --e4/LY <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to seff-insure for workers' compensation. as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br />have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />or the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: a .5 — <br />Carrier: Policy Number: $1 3 o ir 9--e 1 <br />i certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers compensation laws of Califorh and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 Labor Code, I shall <br />forthwith comply with those provisionS. <br />Data: c.57 91tr)? Signature: <br />Printed Name: <br />WARNING: FAILURE To SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND COLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEYS FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION ane OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofc-s7 licensed authorized representative), <br />hereby authorize (print name) __17 <br />, _ <br />to sign this Zan Joaquin County Well Permit Application on ity bona I understand this authorization 15 .valid for <br />one (1) year and is limited to the work plan dated on the front page of this appilcatIon. <br />51.20-52 Ml