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01/06/2008 22:21 5306628052 WDC EXPLORATION PAGE 03/05 12/27/2007 13:59 536E'"'1052 WDC EXPLORATIC PAGE a3/84 DEC-27-2687 11'06 L Cpm2R1q "f 1707 93!1 6649 P.03iO4 j �n� S,ti�l 51Ib $an Jc2qu)n County Enviro"M@Rtal Health Department Unit N Weft permit ApPlicatian' uppje� JOIE ADDRESS. a A 7a�..� (� 'AkERMIT SR#: 0�301�� LICENSED CONTRACTORS DECLARATION (Leg) I hereby affirm that term licensed under the provisions of Chapter 9(commencing with Section 7(1(;0)of 01vlston 3 of the Business w1e professions Code and my license iS in fuA fo"and effect. Licanse# 2au- �Expiration Date: Date. t2 e Contractor; r aS _--- Signature: Title: Printed name: cc4.4 LIMAF _.. WORKERS' COMPENSATION DECLARATION + I hereby aflirrn under penalty Of 00rjury one of the f iaMng Omlarationt:: (CHECK ONE) I have and wUt maintain a Cehlltcete of consent to serf insure for workers'campe.nsattpn,as ?r�vlded for by Section 3700 of the Labor Code,for the perforrnanw of the work for which 1pe perm t is ipsN.vd. �G I have and will mafntain workers'c0m0eWhon insurance,as required by Section 3700 of term tabor Cade. for the performance Of the work for which this Pefrltit is lsae:ed, My workers'compensation o au ante carrier and policy numbers are: C0.mer: Awl t'..YI coutl„I I15w- I bL Policy Numbers t certify that in the performance a the work for which thlS permit is lmsued. I shall not emptey,1rir.paraon in any manner so as to bewme subiw to the workers`cQmpensatiorl Iavrr3 Of Califomrt afar a5trAit that if) should become subject to the workers,wmpen9efion provfsWnS of Section 3700 of the L813r[e t'+t.efe 1 N fort w to comply with these provisions. expiration Date:,G _SigrMUre: / Printed Name: WARNING. FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAYMUL,AND SH at,a..SUBJECT AN EMPLOYER TO CRIMINAL PENALTINS AND CIVIL.FINES Up To ONE WjXORSD THOUSAND OOLLAAS (b100,0004,IN ADDITION TO?HC COST OF COMPENSATION,f"REST,ATTORNEr3 Fr=eS,AHD VAM1AGEs AS PRMDED FOR IN SFC rnN 3r”OF TME LABOR CODE. AUTHORIZATION FOR MAIR THAN CS7 SIGNING PERMIT APPLICA TION t' (SiOnSIUM o8G57 Iicenead authorfssd nrpmrsantative), ftftby autharete(print nems) to sign thla San Joaquin County Well Porno APplacatlon on my behalf. I understand MIs au"Arattan Is va11d for ane(1)year ones Is NrnitaA to the work plan aat*4 an the front page of this oppl"tion. s-29•t)!t MI LI M 29-02-Get 1 ua1rb.