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San Joaquin CounIty Environmental Health Department Unit IV Well Permit Application Supplement <br />iiit_eLP9rmit APP.I.10AtIon Supplement <br />JOBADDR :n county Environmental Health DepartMent Unit <br /> PERMIT SR#nn <br />, JOB ADDRESS: 1P/Q5 AC .F.Ycz_12ILM&.__ PERMIT SRP,--Liti <br />5-T cr,r.-to LICENSED SOcittillikifflayiEELACATANOASD) <br />teFt glatiKF,gi g (.66ififfletzial4gyikitISsailtrtniV0Odlistif 'Efts ion <br />3 of the zitnya tifig • cfN Ragielarki tercesixtlaeffittct. <br />Licensiely6art Art /5( t,) _Ekflerf-Mik - - <br />1..ICENSE <br />hereby affirm that liren <br />Title: <br /> <br />lip Si II I • <br />4111,1` ' I%' <br />Date: Date: <br />SignattAttrztur.: <br />JA144 191663U'r-1.1 <br />f2 @' 10:57 20946 .6 <br />CASCADE DRILLING -r-NC <br />AGE STOCKTON <br />PAGE 02 <br />PAGE 02/02 <br />PrintetliMr <br />I hereb <br />I h <br />by <br />WORKERS' COMPENSATION DECLAHA I ROI <br />WORKERS' COMPENSATION DEC <br />I hereby ;Ann under penalty of perjury one of the following deciaretio, ONE) <br />affirri unclercPeriV 9f krijeigiffatiOitIA1444019104VMFOVOlebri(GeHECIAraitflets Provided for have en wi m m a <br />bv. Section R00 of the Labor Code, for the Perfortnen0e of the work for which this permit issued. <br />ye and will maintain a certificate of consent to self-insure for worlsers omie,s0iwijiwrve&afo <br />19Q4Q94fvtitlerihttkair Godenfbccittlfritlitreirtlie 4t)&11;6 lirguip-f <br />forth. perforrhance of the work for which this permit is issued, work° co <br />ye arackul41141010840Y ceikiliktf3' pensatt n insurance, as required b Sec 'on 700 f e Labor Co <br />e perform permit ipcipqw4milleot: pp__ <br />I certify that in the performances of the work for which this permit is issued, I 3halI riot employ any person in <br />ier: anY Manner Si) as to become subject to the worPamObilosfiefgpri laws of California, and agree that if I <br />should become subject to the workers' compensation pray s of <br />I c rtify thattheitheqeskottettgastPfll*Wigt for w ich thi <br />S <br />forthwith comply with'those proiiki Name: <br />Date: WARNING: FAILURE 1'0 SEC 3' <br />AN <br /> <br /> <br />COMPeNSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT <br />EMPLOYER TO CRIMINAL. P NA17141111rt <br />(1100,000.), IN ADDITIOVS.A. GT 9F COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAPIAGe$ AS <br />PROVIDED FO N IN 5EC I AROR CODE <br />ITATUZAM PaiReNFIIIMASANCOMAitaktgilidignattlePAilliGge SUBJRI <br />EC <br />haroby authorize (OM name <br />sign this tagaZa1wmaP,-.§7.4igaiNGRERMITeAdifittleAgrtfiter <br />one (1) year and le limited to thc work pan dated on the trrillgfiltrI ticavegivid authorized representativ <br />hereby aatia-gstilitenet-- <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 application. <br />8-29-02 / MI <br />I h <br />for <br />ca ier <br />e, <br />Ca <br />any mannee.rolanreztv,til to the wor <br />h RINNIS tatattlYirb <br />all not employ any person <br />laws of California, and agree that if I <br />mil S7150 of the Labor Code, I sh <br />••• • - . : .1 *,• _ <br />WARNING: FAIL <br />AN EMPLOYER • <br />($1 00,000,), IN <br />PROVIDED <br />M AL TIES ANIMISM FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />04*.10 RIENSATION INTIBitheiTTACHYFINIEW5IPEWIRMPBMItft''AS <br />I <br /> <br />E. C at/