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Apr 12 01 07: 48a r ones 5-1 51 p' 2 <br /> �f �1 <br /> OWAI <br /> San Joaquin Coun Environmental Health Services,Unit IV Well Permit Appy vn Su I emitZi 1 <br /> /4��5 �o Cin � y J <br /> .lOB ADDRESS: Iva � �� � PERMIT SR# �G <br /> 0° <br /> /Z&7 AgA 41iiiO(411"n <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> l hereby 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 effect. <br /> License <br /> (9 b Expiration Date: <br /> #: <br /> Date:q r _ <br /> 12- Contractor:- 1�L5C En 1 Q <br /> Signature: Title: <br /> Printed name: »>h ci !Q.SCAA <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _l have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor 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 /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier an``d policy numbers are: <br /> -� <br /> Carrier. J o Policy Number: ^!� <br /> _I certify that in the performance of the work for which this permit is issued,l shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Date: - a'O Signature:. <br /> Printed <br /> ignature:.Printed Name: -�-3m\k-a ISC� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PADDITION TO <br /> SECTION ON 37E COST <br /> OF THE COMPENSATION,OR INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR <br /> C), PL-Z, (C-57 licensed authorized representative),hereby <br /> authorize dem sJ r <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 /> 5-17-20001 Ml <br />