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f.rti_By: Gregg Drilling & Testing, 7"c. ; 925 313 0302; Jun-7-00 '3:53; Page 2. 3 <br /> '08/07/00 15`.40 X818 5120 PHILIP COLUMBIA '1%0001 f�jOn3 <br /> / <br /> 09/07/2080 1,3:8F, 2094683433 <br /> FIFTH FLOOk <br /> PAGE b? <br /> Sen Joaquin County Environmental Health Rprvlet$, Unit IV Well Permit Application -Supplement <br /> JOB ADDRESS! 76 S! Af_So47 .<�.Qr'e,¢� ")/ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisiom' of Chapter 9 (commencing with Sect er <br /> 3 of the Business and Professlons Code and my license is In full force and effect, <br /> License l upiravon Date: <br /> Ole <br /> Date: Ceniractoraa <br /> Slgnaturo: IFTitle: <br /> Printed name: <br /> WORKERS' COMPENSATION mcLARATION <br /> I hereby affirm under penalty or perjury one of tho following declarations: (CHECK ALL THAT APPLY) j <br /> I have and will maintain a eertificnte of consent tt�self insure for workers'compensation,as provided for by <br /> Section 3700 of the Lsbor Code, for the perfomt#nce of the work for which this permit Is fssuad- <br /> I have and will maintain workers'Compensation irhourance, as required by Section 1.700 of the Labor Code, <br /> for the parformance3 of the work for which this peimit Is issued. My workers' CoMpensotion insurance <br /> carrier and policy numbers are: <br /> Carrier: �1� Policy Number 4S 0i!�'�i~ <br /> _I certify that In the perrurM ante of the work for w6ieh this permit is iaausd; I shall oot errp.., s, , <br /> any manner so as to become subject to the worWs'compensatlon laws of C2liforn;a. and SS <br /> should become subject to the workers'compens4lign provisions of Section 3700 of the Laeor C,=u <br /> forthwith comply with those proviVor,s- <br /> Date: Z 7196 Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPEf1SATION COVERACIF IS UNLAWFUL,AND SHALL SU3JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES up TQ ONE FtUNDRED THOUSAND DOLLARS <br /> (5100,090.),IN ADDITION TO THE COST OF COMPEHBATION,INTERTEST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR COIJtE. <br /> t I <br /> I, ���rll t�hlJ' I�I�Q�Q,t�' ♦ (C•57 Ileensed authorised representative),hereby <br /> authorize 'LAliz <br /> to sign this San Joaquin County Well Permit Application an my behalf. I understand this�u[horizatlon is ^ ' <br /> one f ver and is limited to the work plan dated on th a front page of this application. <br />