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JAUU <br /> qq ; ; .2 U; GUUU UU : G, 9 1'.;iti '71. 3k1 :! N (f76fl 'C.r?STA04'R (f :a• :W 7 ,r_ i`N+ 2,, <br /> � 1 4dJ pri Id „Gi <br /> • ' % BpN1 40u9 " P. . 6YC 1 : ii I Jdi1l0 ll In C . f Q <br /> I <br /> San Joaquin County E vironmental H901th Department Unit IV Well Permit Applicationnpup it ment <br /> JOB ADDRESS: V 4&It PERMIT SR#: Db (` <br /> LICENSES CONTRACTORS DECLARATION (LCD) <br /> I horeby 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 affecL <br /> Lfeense ,7; S f R y B Expiration Data; b S - 3f -as0 7 // <br /> Date: Contractor: rsi jllm uNt ) IWL PIP Ge,*/ AA A/at IkQw4o 14l. a-'L <br /> Signature: . <br /> Printed namr +tA a 4' �rfhErlrtrtF9^ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby9affirm under penalty of p"Lify one of the following dedarations: (CHECK ONE) <br /> _ I hnba and will maintain a certificate of consent to self-Inure for workers' compensation, as provided for <br /> ,�b^'y Section 3700 of the Ls Or Code, for the performance of the work for which this prrinit It issued. <br /> +r l haye and wIff maintain workers' oompe nsation insurance, as required by Section 3700 of the Labor Cade, <br /> for the performance Of the work for which this permit Is Issued, My workats' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. HitA-ii6.ip ks PoticyNumber: .9AWdVILN+t7N31 _- <br /> I certify that in the performance of the work for which thls permit is Issued, I shall not employ any person In <br /> arry manner so as to become subject to the workers' compensation laws of California, and agree (hat if I <br /> should become suNectto the workers' compensation provislons of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those pmvAslons. //^^ <br /> txpitatiion Date: _ - e'(• Ole6w� Signature: GA ' K ' r) <br /> Printed N o <br /> WARNINu`: FAILUhE TO GFOURE WORKMS' COMPENSATION COVERAGE Is UNtAWFUL, AND SNALL 5UgJECT <br /> AN 9MPLCYERTO CRIMINAL PENALTIES AND CIVIL HNij$ UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1001O0u.);IN AbUIT(ON TO THE COST OF COMPENSATION, INTERhST ATTOMEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SUCTION 3706 OF THE LA90R CURE <br /> AUTHORIZATION FOR � G <br /> THAN -57 SIGNING PERMIT APPLICATION <br /> I, "' ` (elgrwture ofGA7 licensed surnorlmd rupreserrtsdve), <br /> hereby Authorize (print nam F2 T— :S'2 <br /> to sign this San Joaquln County Well Permit Appgaa0on an my behalf, I understand this authortortion a valla for <br /> one (1) year and is limited to the work plan dated on the front page of this application. <br /> 8=29421 EAI <br /> EH1529424ei <br /> A/37r01 <br />