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11/08/2005 13:59 2094658773 5F'EL;I Orf tx1ILUKAI r-#4%= oc <br /> s <br /> #lain Joaquin Cour*8nviro0rt ertt l Health 060111MOnt Unit V Well Permit Appli atio ppanent <br /> JOB ADDRESS: WIS.- 1 IR 1 C�N.I Y IA_jl" . PERMIT SRO: <br /> LICENSED CONTRACTORS DEC RATION LG � <br /> i <br /> 1 heneW affirm that I am licensed under the:p1o4INOns of Chapter 8(camrnencing with Section 7000)of Dlvislon <br /> 0l'the Business and Professelons Code and my llo0nss IS In full enol effect <br /> 3 <br /> Liaxrse#: 5 <br /> Expiration D 04-30-07 <br /> (Date: 1 S' -0 5Contreat S' Ina <br /> • Regional. Manager <br /> 181gnature: - <br /> Prlirted name: JJ <br /> WORKERO' COMPEM1MT10H DECLARATION <br /> I hereby affirm under penalty of perjury one of the follwMng decilm done. (CHECK UNE) <br /> _.i hwi a and will maintain a cerdficaft Of Consent to neWinsure br workers'compensation,as provided for <br /> s by Section 3700 of the Labor Code,for the peftff lane of thQ work for which this permit is issued. <br /> have and VIII maintain woricera'compensation In•unrtrm,as required by Suction 3700 of the Labor Code, <br /> for the performance of the work Tor Which this perrsttt Is lasued My workers"compensation Insurance <br /> carrfer and policy numbers are: <br /> Carrier: National Union Fird Paltry Nu bar; ,1177.850 <br /> I certify that In the performance or the work p tt is issued,i shall riot employ airy person In <br /> any manner so as to become subject t0 t1I ttcet'tt'co n stion Tawe of Caliromie,and agree that If I <br /> should become subject to the.workem ao` salon provl a of Seal n 8700 of the Labor Code, I shall <br /> forthwkkh comply Wth those provislone. <br /> Rx olra<tlon pate: n 4_��0 7 Sipnaturs¢ <br /> .j <br /> F.11" eti Name:., <br /> 1Ar/,RN NG-FAILURE TO 8000PA WOR�'8** JWo <br /> 10 <br /> (W lei E HL4NDRE[>'THFUL-USD IaG LL SU13JECT <br /> AN OP'LO LLARB <br /> ' AIiI+I�Y'-,t�l'�►,ANQ.DAMA©t?8;J18--_ <br /> PRDVII3a17 FOR-IN 8EPMON 9T08 as <br /> AUTHORIZATION <br /> 0001111. <br /> e <br /> AUTHORIZATION FOR Qom$THAN 047 Sl NINU PERMIT APPLICATION <br /> NXIIAW tyre ofc4t licensed authortod representative). } <br /> herbby aathar m(print nMme t+A 1110 V 4 r 17MY-8 N <br /> to elan this San Joaquin county Well Permit Applhfatlon on my kof Rlf- I understand this authorization IR valid for <br /> on-it(1)yast:and Is limped to the work plan ddid on 1(ie front page Df this Application. <br /> 3-02 f IM <br /> iFltb:9.OR-001 <br /> b/2tA4 <br /> I, . <br />