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Nov. 17. 2006 11:39AM Advanced GeoEnvironmental <br /> <br />N o. 6823 P. <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 6td 5- rc,, (1-±1, 7 <51-- PERMIT SR#: q 9 r2". <br />2-CA/q fh r/9/ <br />LICENSED CONTRACTORS DECLARATION (ISJ2) <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 />License #: C- - 5 7-4- 6 7 Z— 6 ( 7 Expiration Date: 6/ 3 0/ 0 7 <br />Date: k ‘ 7 ( .7 / 0 6 Contractor /IA 1-1-6 t -e---(_ PR (LL-( )j 6 f).0—/ C0J), <br />Signature: _.---k------------ Title: \I r <br />Printed name: PA,-)_ 6 2_6)- 6 <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 self-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 />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />carrier: zAl-leoe-)-)116t - ik-6 • Policy Number; " 7514 - 0 1 - o 2- <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 California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: q/ /6" 7 Signature:. <br />Printed Name: 0.74\k-2__ 6 f_ei.4 6 <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 DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST. ATTORNEY'S FEES. AND DAMAGES AS <br />PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I. (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) It4_12,-J1 <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 I MI <br />EHD29-02-001 <br />.414, IA4