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PAGE bZ <br /> FIFTH FLOOR <br /> 10/27/2003 11:12 20946830 <br /> • <br /> San Joaquin County <br /> Environmental Health Department Unit IV Well Permit App <br /> lication Supplement <br /> hl PERMIT SR#: <br /> JOB JADr)RESS:26 11 <br /> Traup (4 <br /> LICENSED CONTRACTORS DECLARATION %LCD) <br /> 9 commencing <br /> with Section 7000)Of Division <br /> 1 hereby license's In full force and e��//� — <br /> affirm that'am licensed under the provisions of Chapter <br /> 3 of the Busin(e�ss and Prroofession /00� my Fxplration Date: <br /> License#: `- s /, f v /l <br /> ��Q /J`7 Contractor: „wy <br /> Date: Title: <br /> Signature: <br /> Printed name: A TION <br /> WORKERS' COMPENSATION DECLARA <br /> of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 hereby affirm under penalty P J ensation,as provided for by <br /> erformance of the wok for which this permit Is issued. <br /> I have and will maintain a certificate of consent to self-insure for workers com <br /> _ Section 3700 of the Labor Code.for the p by Section 3700 of the Labor Code, <br /> ensation insurance,as required kers' compensation insurance <br /> 1 have and will maintain a work <br /> rs'comprk for which this Permit is issued. My <br /> for the performance of the o <br /> carrier and policy numbers are. <br /> t policy Number: person in <br /> Carrier: �* rmit is issued, I shall not employ any <br /> that in the Performance of the work for which this Pe compensation laws of California, and agree thatl if I <br /> _I certify the <br /> to the workers compe <br /> shall <br /> any manner so as to become subject rovlsions of Section 3700 of the Labor Co e, <br /> should become subject to thew ons.compensation <br /> forthwith comply with those provisions- <br /> 1-1 <br /> / Y <br /> .�� �0 (- Signature, <br /> Date: <br /> Printed Name: V WFUL,AND SHALL SUBJECT <br /> WARNING-FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNI..A <br /> DI110N TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAR <br /> ($100,000.),IN PD <br /> PROVIDED FOR IN SECTION 3706 OF THE t,A60R CODE, <br /> re ofC-57 licensed authorized represen )+ <br /> tative <br /> (slgnatuer <br /> her®by authorize(print nam®) <br /> �_<<-D . <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 work plan dated on the front page of this application. . <br /> 1.25.02!MI <br />