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71/04/10 09:SOAM A11 WE 10bandonment 530.644. 1439 Isp.03 04 <br /> San Joaquin County Environmental-Health Departmennt Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 12ok S \� '�f- " '' ERMIT SR#: <br /> LICENSED <br /> --- <br /> LICENSED CONTRACTORS ')ECLARATION (LCD) <br /> eby <br /> affirm <br /> 3 ofrthe Busineeby affirm ss and Professions Code andmylicense ins of s in fullllrforce and effect. <br /> (commencing <br /> with section 7000)of Division <br /> (A 4A 'F �q �Expiira�tiicc i Date: �--License <br /> 7 IU�I 1 I C)! �L —�L,t:3 <br /> Date: Contractor: <br /> Title:t�rP`t�0nA <br /> Signature:� '�-- <br /> �n V a S i�� SL <br /> Printed name: t-- <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 ceof rti41 ficate compensation. <br /> this ned for <br /> by Section 3700 of the Labor for eperformanceof the wok for which permit s issued, <br /> X I have and will maintain workers' compensation insuran,:e,as required by <br /> Section <br /> 3700 onof the the <br /> Labor ode, <br /> for the performance of the work for which this permit is i sued. My <br /> carrier and policy numbers are: <br /> u __Policy Number: <br /> Carrier: <br /> I certify that in the performance of the work for which th s permit is issued, I shall not employ any person in i <br /> any manner so as to become subject to the Workers'co npensation laws of California, and agree that if I <br /> should become subject to the workers' compensation p ovisions of Section 3700 of the Labor Code, I shall <br /> with those provisions. -- <br /> forthwith comply -' <br /> Expiration Date: IZ Signature <br /> Printed Name: NLAWF L,AND SHALL <br /> RKE ONE THOUSAND DOLLARS <br /> WARNING:FAILURE TO SECURE AN AND OCIVPL FINES t P TO OE AH <br /> U6JECTLOYER TO CRIMINAL PENALU6JECT <br /> (PROVIDED ORM SECTION THE COS THE OF <br /> FLABOR CODECOMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> AUTHORIZATION FOR OWER THAN C-57 SIGNING PERMIT APPLICATION <br /> _ r. <br /> ;signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on n y 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 /> 8-29.021 MI <br /> EHD 29-02-001 <br /> 6122/04 <br />