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OCT-07-2003 16:34 FROM:PRECISIAkSAMPLING 510 237 4574 TCW4603433 P.2/2 <br /> 1U/U//U3 LIIh 15:4N t'A3 03W00 414J, bkUAitil KlA Ug1)(t� <br /> A�lb <br /> San Joaquin County E ironmontel HA®Ith Department Unit IV Well Permit Application SuP ernent <br /> / <br /> c>J f-As-r o¢ Pk I,-rA s PERMIT $R#- <br /> 10B ADDRESS: C�et��-� � <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensod under the provisions of Chapter 9(commencing with SOct!Cn 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full ferce and effect, <br /> License#: Expiration Date: �- ----- <br /> Date: <br /> f o D Contractor,/ <br /> Signature: 'title: <br /> printed name. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under ponalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificato of consent tv 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 /> 41 have and will maintain workers'compensation insurance,as required by Section 3700 of ine Labor Gode, <br /> for the performance of the work for which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbOrs are: <br /> Carrier. Policy Number: O( <br /> ' �`� <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 tie workers'cornpansation laws of California, and agree that if 1 <br /> should becerne subject to the workers' rrom cation provisions of Section 3700 of the Labor Cade, I shall <br /> forthwith Comply with those provisions. <br /> Date: 1 L � —Signature, <br /> Printed Narrw:... <br /> WAANING--FAILURE TO SECURE:WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CMMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1pp,OtlO,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTiQN 3706 OF THE t_ABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (Signature efe.571iaensed authorized representative), <br /> hereby authprin(V nt name), <br /> !�'I A-r- r7Ot;�7 �~tGarn4kriX l .0 $:.11« 6.ti�� a <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 f MI <br />