Laserfiche WebLink
Jun 02 07 09 : 42a Fisch Drilling 707 - 766 - 3571 P • 2 <br />+ <br /> FROM ENVIRONEERING 4N� <br /> FAX NO. : 9258389621 +n. 01 2007 05 : 32PM P2 <br /> : <br /> ea <br /> San Joaquin Coungr EnvlronmentaJ Hlth Departmenn <br /> t UR Itl Well Permit Application Suppleme - <br /> JOB ADDRESS: 3/6 . S 61, �/7l+00 Si. PERMIT SRM:� ----- - <br /> 5 i ock pod , CA <br /> LICENSED CONTRACTORS DECLARATION (.LCD) <br /> P) <br /> hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Sectior b000) of Division <br /> 3 of the Business and Professions Code and my licence is in fun tone and effect. e <br /> �n fes, Expiration Data <br /> License 0: <br /> Dais: r7 <br /> i - C / <br /> Con had or: <br /> FIS �+ �2L L� I •�— <br /> l o ` - <br /> Tkfe; GG c is ti ' 2 <br /> Signature: � [� <br /> Printed name: • I ' 1 ` c- -4� <br /> WORKERS' COMPENSATION DECLA ION <br /> I hereby affirm under penalty of perjury one of 1PIe following declarations- <br /> CHECK ONE) <br /> Ihave and will maintain a certificate of consent to self-insure f workers' compenaetion, as provided for <br /> Eby Section 3700 of Uta Labor Code, for the performance of th <br /> rk for which this permit is issued. <br /> ✓ 1 have and will maintain workers' compensation insuranc as required by Section 700 of tlhe Labocre ode, <br /> -- for the pertormance of the work for which this Permit is i ued. My workers' romps <br /> nsaticarrier and policy numbers are: mi <br /> Carrier: e l • olicy Number: <br /> � <br /> I certify that In the performance of the work far ich this permit :s issued, I shall not employ any person Irl <br /> any manner so as to become eubjebt to the rkers' provisions of of 5eclion 3700 of California,ws of and agreethat If I <br /> e Labor Code, I shall <br /> should become subject to the workers' c ensation p <br /> forthwith comply with those provisions. <br /> Expiration Date: '- ! - UZ Sign re- <br /> PriMetl ams: _ �- <br /> I <br /> NARNiNG: FAILURE TO SECURE RKlRS' COWENM'T UMP TO paNE N1E21iOREO TTHOUSAND OOLLARE8 UNLAWFUL� AND SHALL UaJECT <br /> AN EMPLOYER TO CRIMINAL PEN TIOp ES AND CML FIN <br /> pRpVI ocalp IN ADN SECTION THE LABOR CODE.ON ��RE3T, AT[ORNEY'S FEE5, AND DAMAGES AS <br /> AUTHORI7JATIC/ FOR OTHERTHAN CZ7 SIGNING PERMIT APPLICATION <br /> S csignature ofC57 licensed authorized roPrveenrative(, <br /> hereby authorize (grin name - IN ' �p <br /> j <br /> I to Sian this San J Olin County Well Permit Application on my behaff. I understand this nuthOrtzation is slid for <br /> one (1 S Year and limited to ew vert pian dated On toe front page of this app <br /> "Callon. <br /> a-24-02l MI �_ <br /> cHn 29-02-rA I <br /> crzam+ <br />