Laserfiche WebLink
PAGE 02 <br />AGE STOCKTON PAGE 02/02 <br />San Joaquin Cou4 Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ACeDREISI9in dounty Environmental Health Department Unit 43111WerngfetlIcatIon Supplement <br />JOB ADDRESS: LPY 5 c tfiFYc, /y4( PERMIT SRO: .0 0 `"•1ki? <br />LICEtsfidi b.6KfRilt6ORS QE,GLARATION <br />LICENSED CONTRACTORS 11):LAKA I 11.114 (1.-W7 <br />1 hereby affirm that I am licensed under thezovisions of CM2pr gruigaqckirtci%let.90Ftlict83,39gpapkitiivi ion <br />3 of thelffiegfrit§15113fltOrbfftg'ketterTaVailtZ,TRINeg rAWAg#Ct• 3 of the Baines* end Profeeetona <br />LicenseLtaftse 0. f...e..4r7 , 5 to Evitaboonaoin: 1 -__: <br />Date: <br />Signatteignaturs: <br />Print4ORRICO. na"HE <br />WORKERS' COMPENSATION DECLARATION <br />WORKERS' COMPENSATION DECLARATION <br />t nereby affirm under perielty of perjury one of the followIng declarations: (CHECK ONE) <br />I here y affirm under pffialty of perjut one of the followinlymilar400rArsighigrAnClitiPas <br /> <br />have and wA metntain a CerbflOCIte er consent to sm provided for <br />-nd" 37_00 of the Leb4r code, for the perfonnelee of the work for which this permit is issued. I h ve idIT aintain a ceruncate or consent to self-insure for workers' compensation, as provided f <br />16t19.6WggiqifitRainlkiliiriPs'f€64441faierraueczrallas raquicticirboototignigiStirtAtit 486e5K/e' <br />for the petforrhence of the work for whictt this permit is issued. My workers' compensation insurance <br />1 h ve qafilrftlfilhflaEtkiktririentJemi mpensa ion insurance, as required by Section 3700 of the Labor Co e, <br />forj the perform e of tea° 8A6h permits jssugd. vprOltlee:e!9S;a6rrapturance ca ier &WON rolicy <br />certify that Ini the perfOrtrence of the %sork for wh_lch thrsoermit is Issued, lotion not employ any person in <br />rier• any-ntienffer-.--e-as-44-becontut-subieo tç the rltififdi iect laws of California, and agree that ill <br />should become subject to the workers compensation prov. . s of •;). «Ion 3700 of the Labor Code. I shall- <br />c rtifY Ibrii4ittitick4V9ahaatlie9hilaisienatk for which thief it is ued, I •all not employ any person un <br />an manner, so a beco e subject to the wore ' co i• .ensa P aws of California, and agree that if I sh dieltisec , sh II <br />forthwith comply with those prciyisions rame Name: MCNLY-1 <br />WA.RNIPirt: FAiLuRP TO AMIC*10001.3ERS . COMPENSATioN covEPAGE 13 UNLAWFUL, AND SHALL. SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES ANC) C/ViL FINES LIP TO ONL Hum/0e) ;ROMANO DOLLARS <br />(31oo,000.), IN ADDrT1ON . comPENSATION, INTEREST, ATToRrarS FEU, AND DAMAOES AS <br />PROVIDED FOR IN aeCTION"3 O IatBOR-CODE <br />WARNING: FAIL ii. -;, lifilia <br />sit ::iiir .; CTTEAML riNES UP TO ONE HUNDRED THOUSAND DOLLARS AN EMPLOYER W41/2410c9KNOICIPEEPORPIAIPPAMAiliON. suBJE <br />($100,0cr.), I _Iv . 7. .,T...0 _ ; 01:: . 1 3 Eve/ 5NEATION, I PROVI .' 0 <br /> <br /> Mif21415§4 tailllinageffiS krtrikftaallingleidAa&aAS <br />wZI.it'e ,,\e 0 C(.4_c tiate„, <br /> 4 ovint name' <br />AhrinirRIZATION FOR OTIVER ZWA112;p7Aloci yInif„,FARCAPJAUGAVatilor th sigh this San Joaquin county Weil orT.th <br />one (1) yam and is 3mitatt to the work elan debut on the fru(thriNtdVeltilfelPSOfnched authorized representative), <br />hereby iuttitlikille reirint na;rtn) <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this aplication. <br />8-29-02 / MI <br />by <br />Ca <br />Date: <br />06/19/2003 10:46 19166385611 <br />0$/19/2Ce3 10: 57 20946.7111S <br />CASCADE DRILLING INC