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05/26/2005 11:05 20946587M SPEC RUM EXPLORA N PAGE 02 <br /> San Joaquin County Environmental Health D"Mrtmard Unit IV Well i e ntit Application Supplement <br /> i712JZ/'f 644—G t I®. Ah <br /> JOB ADDRESS: 27�7 77— PERMIT SR#; <br /> LICENSED CONTRACTORS ECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions O Cha r 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in II force and effect. <br /> i <br /> Licen 512Expl rstlo Date: 4/-30/06 <br /> Dat • Co ctcr: i <br /> �? 1 <br /> Slgrlatu Title: <br /> Printed name: <br /> .i <br /> ORKERS' COMPENSATI N 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 tleff-in ure for workers'compensation,as provided for <br /> by Sedion 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> i! I have and gill maintain workers'compensation insurana , as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this perm- It is Issued. My workers'compensation insurance <br /> carrier and policy number';are: <br /> 11 "71 SCo O <br /> s <br /> Carrier: Poliay Number: <br /> I certify that In the performance of the work for which this ermkt is Issued, 1 shall not employ any person in <br /> any manner so as to become subject tat 'com nsation laws of California, and agree that if I <br /> should become subject to the workers' mpen n pre isions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with moose provisions. <br /> h Expiration date:(L4_Z 0.110 fi—5fSnature: <br /> Printed Name: J m Kle'nfeld <br /> 'I WARNING:FAILURE TO SECURE WORKERS'COIMIPENBATiON OVERAG UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIiN1128 UP TO ONE HUNDRED THOI.ISAND DOLLARS <br /> 1$100,000.),IN ADDITION TO THE COST OF CO MIPti'iNfS MON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN 3ECTION 3706 OF THE LABOR CODE. <br /> 4 <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i, Ji IC licensed authorized ropmeentative), <br /> heisby authortze(print name IC- - Ll. Gi 1Je- i"PJ& <br /> to sign this Son Joaquin County Well Permit Appileadw on my behalE i undereband this authorization Is valid for <br /> one(1)year and le limited to the work plan dated an the ftrrt pa Re of this application. <br /> 0,2642 I MI <br /> EB D 29-02-001 <br /> �rz uoa <br />