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06/10/2005 11: 11 2094656& SPECTRUM EXPLO TION PAGE 02 <br /> 06/10/20)5 10:51 F-A-1 209 94806 , WPRECTRUM 10002 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: f," _ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (�C�) <br /> I hereby affirm that I am /(tensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 5 of the SvsinlEs Ind Prefellions Code and my license is in full farce and effect. <br /> License I51Z214�G Fe ,E-xpiration Date: L <br /> [late:_ _ Contractor: i✓w_o /-Ct^'+^ �fl�—G�t l� <br /> J6Signature; Title: AA <br /> Printed name: <br /> WORKERS' COMPENSATION 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 self-insure(or workers' compensation, as provided for <br /> by Section 3700 of the Lehor Code,for the performance of 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 /> tar the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier' Policy Number: <br /> 1 cerlify 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 the w ompansation laws of California, and agree that if <br /> should become subject to the workers' c ensation revisions of 5 ion 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date; Signature: <br /> Printed Name: <br /> i VARNING; FAILURE TO SECURE WORKERS'GOMPENSA71oN covKRAGg IS UNLAWFUL,AND SHALL SUBJECT <br /> IiN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (11100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> tAUTHORIZATION <br /> o FOR <br /> `OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, J6✓, k-�Ge� i—011- ^� (signature of"? li"nsed authorixad representative), <br /> hereby authorize(print name) —)D C Li.Q-rf, <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 war*plan dated on the front page of this application. <br /> f-26.02 I MI': <br /> I <br /> I <br /> FFC]29-P7.04i <br /> 6/2:/04 <br /> 06/10/2005 FRI 10:59 [TX/RX NO 61251 002 <br />