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II <br /> Oct 05 05_ 11 : 08a GREG DRILLING 825n0302 P. 1 <br /> N f to- I <br /> San Joaquin County Environmental Health Department nit N Well Permit Application Su plemerrt <br /> JOB ADDRESS Y-536S A/e-;s-/ z �// &rIvIA PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION =LCD <br /> 9 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 N: Expiration Date: Wo <br /> Date: t� Contract r <br /> Signature: lu <br /> Title: <br /> Printad name: <br /> WORKERS' COMPBNSATIO 4 DECLARATION <br /> I hereby affirm under penalty of perjury one of the follc**ng d arations. (CHECK ONE) <br /> I have and will maintain a cerlincate of consent to self-ins are for workers'compensation,as provided for <br /> __�..by Section 3700 of the Labor Code, for the performance a 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. Policy umber: 'J ti QcE;C>Z 1 J <br /> I certify that in the performance of the work for which this;ermit is issued. I shall not employ any person in <br /> arty manner so as to become subject to the workers'corn ensattort laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 700 of the Labor Code,I shalt <br /> forthwith Comply with those provisions. <br /> Expiration rate: bl?)db�igrlature:—n. <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION OVERAGE ES UNLAWFUL,AND SHALL.SU13JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES uplo ONE HUNDFtSO THOUSAND DOLLARS <br /> (;trr8,dat1.),IN ADDITION TO THE COST OF COMPENSATION,IN EREST,ATTORNEY'S PEES,AND 10AMAGES AS <br /> PROVIDED FOR IN SECTION 3709 OF:THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (sf nature vfC-S7 licensed authorized representative), 1. <br /> hereby authorize(prink name) , 6 <br /> I� <br /> to sign this San Joaquin County Wall PermitApplicatton on my half. I understand this authorization s valid far <br /> one(i)year and is limited to the work plan dated on the front Palle of this application. <br /> I� 8-29-021 M1 <br /> I <br /> '4 EHD29-M-001 <br /> I 41304003 <br /> y <br />