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09/2312003 10:27 2394571118 AGE STOCKTON PAGE 02/02 .. <br /> f <br /> t <br /> 3an Joaquin County!environmental Health Department Unit fV Well Permit Application Supp4ment <br /> rc- <br /> 0 ADDRESS: � Nth PE SF2#: <br /> 4 �._ 1 _ PERMIT — - <br /> S 1 CP <br /> LICEN$I D CONTRACTORS DECLARATION -(L!CD <br /> I hereby affirm that I am fa:ensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the&mtness and Professions Cods and my license is In full force and effttcl. <br /> Linc nse#: 67P 617 E*iratlon Date:._ 3 Zy D <br /> Qato; d-S cCranntractor l`q l'z til_pQt� �1,/(a .G�vi1 R>�J�-`lira GaK <br /> P'rinte'd name: �+� <br /> I her rfay affirm under pena.fly of perjury one of the f0flowing Qeclaratlons: (CHECK ONE) <br /> _ f tl3ve arms wii)rrmaintaiir a certificate of ccarmsant to sQtf insure for workers'compensation,as 0rOvided far <br /> t ty srzcttrx,37QQ of the labor CodQ,for the performance of the work for which thls pormit is Issued- <br /> 1 have end will maintain workers'cOmpensaVOn fturWce,as required by$e0tion 3700 of the 1.8bor Code, <br /> 13'r the performance of the workfor which this pemtit is Issued. Myworkeru,compensation insurance <br /> G arrier and policy numhm are: <br /> GarrSer, ���'✓ - _P'olityNumbr. 1556617 2(743 <br /> e <br /> f rertrfy that in the per(cmTn&ca of the work for which this permit is issued,)shag not employ any parson in <br /> a iy manner so as to bes:ome subject to the workers'comPensatton taws of Caftmia,and agree that.Pf I I <br /> s Ovula become subject;.a the wftem,compensation Drovfsiorts of Section 3700 of the Labor CodQ.I shall <br /> fc rttlwifh Mnpty with thttse provisions: <br /> Prinad Name: <br /> m WMN NO:FAILURtr To SE-OURE WORKERS'COIItIMSATION COVERACe 1'3 UNLAWFUL,AN!!SHdr!SUBJECT <br /> AN E PLaYEft TO CaitMINAt,t'ENALTlks AND GVf1 FINES Up lb C"HUNDRIED THOUSAND t7QLtJ1RS <br /> PROV1 X10 FOR N S CT)ON:tTGd�THE LABOR COp T OF µ i S T,ATTORNEYS FEIES,AND aAiYtAGt:S AS <br /> AUY HgRIxATlQI+I FOR OT�IER THAN C_57 STONING PERMIT APFI.ICATION <br /> •"-- ...�....—. �.--.--.--...._...._(siyn�gsrre ofCv�'3'Ircenaad a�ufhorf�ed rnprasaxf�tive), <br /> tremby wmwrtre(Pefnt rt mhe). ,,..tom a <br /> tv sten thrs San JoagUin Calmly Well Ps►nTdtAPPltoatton an my behalf. I u"er%tand this nuttlo , <br /> �tton is valid for <br /> one(1) vear and is PrmttAd to the work plan dated on the hQnt po"of this aWflcafl q. <br /> e <br /> A <br /> a, <br /> t <br /> Z c 895E Z98 916 'ON xv9 'Q 'Ni Wd 60:1 H1 U-6Z-d'dS <br />