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JU1 21 05 01 : 42p GRF; DRILLING 925- 30302 p, 3DAU <br /> JuL21. 200: 1:381'M danced GeatnvironmsntaI �./ No. 1405 P. 3/3 <br /> R' Olt) <br /> X 1 41.15 1W <br /> San Joaquin County Environmental Neal Department Unit IV Well Permit Application Supplement <br /> Covn4y $4 SAW Jeer vt <br /> JOB ADDRESS:_I'ar ell CAt 9 PERMIT SR#:—zog?'I <br /> N*AA l"Ail nln Ave IlilFloviil Ill <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I 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 m in*4 face and effect- <br /> License#. 10 1iU4 0 F�gliratitxt Date:_. /O 13��(�� <br /> Date: ---?J <br /> O S� COMr�tor- <br /> signature- iWill( � <br /> Printed name: /=� <br /> Wo W COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dedarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to selfansune for workers'compensation,as provided for <br /> by 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 wok for which this permd is issued. My workers'Compensation insil <br /> comer and policy numbers� 7/alre: <br /> Carrier. ��l Y lvl�+�.� Policy Numbel t U y o <br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in <br /> any manner so as to bacOme subject 10 the workers'compensation laws of California,and agree that it I <br /> Should betmme subject to the workers'compohsation provisions of Section 3700 of the Labor Code,1 shall <br /> forthwith compty Wath those provisions. <br /> Expiration Date: L3rgnatum: <br /> u <br /> Printed Name: �4 <br /> WARNING:FAILURE TO SECURE WORKERS'CONIPE VCRAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.},IN ADDITION TO THE COST or COMPENSATION,INTEREST,ATTORNE'Y'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE- <br /> ALJTHOR17ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t <br /> 1,_I"�-q2� 4 (A A,y (signature otCd7 licensed authorized mpresentativeY, <br /> hereby authorize(print name 1. it lAA 44) <br /> to align this San Joaquin County Well Permit Application on my behalf. I understand this authorization is tld for <br /> Zone(1)year acrd u IhMted to the work plan dated on the front paged drip appptlbn. <br /> a <br /> 5-29-02I NI <br /> EHD Z9-02-MI <br /> 6 2/W <br />