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OIL <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application SuppiemsMal <br /> JOB ADDRESS, O bi . El }tti4 , PERMITSR # 0s7�111 <br /> Sd�o� k I dw , GA <br /> LICENSED CONTRACTORS DECLARATION (LCD ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in fuil farce and effect. <br /> License #: lot _ Exp Oats: <br /> Data: 11[) ,Q - _ Contractor: jr� _C} , <br /> Signature: 010PA LIal.i�1 F 1� �19� 4 n in i A. Title: J L'EKz] 1�I_ ± <br /> Print Name ; 3 � <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pahury one of the following declarations: (check one) <br /> _ I have and will maintain a certificate of consent to satf-insure for workers' compensation , as <br /> provided W by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued , <br /> I have and will maintain workers' compensation Insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit Is issued. My workers' <br /> compensation insurance carrier and policy numbers are: I <br /> Carrier:_sT1hL PiQd Policy Number: QL1 l - O can .:-S ' <br /> f certify that In the performance oftha work for which this permit is issued, € shall not amplay any <br /> person In any manner so as to become subject to the workers' compensation law of California , and <br /> agree that If I sheuld become subject to workers" compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Data: 1 D - L" L} — Signature: l <br /> Prink Name: C%C2'('-y-a��\ 4a_ Lj!) I�m - <br /> WARNING: FAILURE TO SECURE WORKERS' CONAENBATION COVERAGE IS UKLAWFi1L, AND SHALL SII aJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES VP To $100M IN ADDITION To THE O❑PrT OF OOUPENIIATFON, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROMDED FOR IN SECTION 37W OF THE LABOR CODE. <br /> 1, Q��'II� <br /> -� � AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> W1 &4 [.'?msrz l a (signature of C=67 licensed authorized representative], <br /> hereby author) (print name) 070144 5111! wmaoi _ � , to <br /> sign this San Joaquin county Well Permit Application on my behalf. I undefstandthis authorization Is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> Ylr�sroaT,a <br /> EFOffiM :Y,hWl <br /> Y�LLFERIIfr APJ <br />