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I certify that in the performance of the work for which this permit is issued, (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 />Date: I b.r)O -2 Signature: <br /> <br />Printed Name: 4 <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 />(S100,000 ), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHE - THAN C-57 SIGNING PERMIT APPLICATION <br />c2.012 c.14`' 1,41/0 A • •I 001titikhignature ofC-57 licensed authorized representative), <br />hereby authorize (print name) E-4411.— t 14421.31/4ati•-• GADV%114...B.L.lrinIAVIotetriielt , <br />to sign this San Joaquin County Well Permit Appticatlon 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 />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: z.Z55 1,1A-t4.01 4 b.bert 1130.5 PERMIT SR#: <br />Vive-VAIM 1CA ci 57-0 Co <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 />License #. 0403cg Expiration Date: /31/.206 (5 <br />Cate; ) Contractor: 4) 1 14/1 ‘) OAK/IP/VA" _ <br />Signature: Title: FIrme5ideik#' <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 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 thls permit is issued. My workers' compensation insurance <br />carrier and policy n mbers <br />Carrier: )olley Number: -37btO -1720°6 <br />JUN23-2004 07:23A FROM: ALL WELL ABANDONMENT 10530(644-1439 TO: 19169398172 P.2 U1/11/21JO/ 1b4 1 HUKILUN