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Sent By: Gregg Drilling 8 Testing, Inc. ; 925 313 0302; Jan-5-01 14:31 ; Nage u'�3 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> /y M 7hbRk7Q,,) <br /> JOB ADDRESS: : 1Wf600Z-LL•4 <br /> .uol3s011dda g141 to e8ed 1=4 a4l uo palgp'ueld Y0016 eyl of PellWtt W Pus.1e6((I.)auo <br /> �e��rG�= ��r��ii�?,ArG�'��'►��L•�11�14°PI`'�`N��(`f°�}�g,.03 <br /> 0;PI1�St uol�¢�oLli azpo4lne <br /> =Iicense�lis,�� <br /> r3 <br /> I hereby t h a I� icensed and thero �111 <br /> fivision <br /> d C . <br /> License#: ,&Mi6i64QjPj tlg: SOL£NOI103S NI 2104 03mMdd <br /> 3 3K101�5WYWYd ONY'S33d S,,�3NilICICIV N11-009 0011,P <br /> S32i31N1`Arl S441A NA31d0 a3:J0 3LLWN9d"IVNIWINOl I <br /> O � 213,kO1dW3 NV <br /> 4803S 0199 :1 <br /> 'a � <br /> ratLs iS oNvoInzim"Nfl S130"3AO0 N411VSNddWOD,SIM1180 <br /> ��99�n�aa�� OLD Ntpal <br /> Uild <br /> Printed name: <br /> WO P ATIOR9M9j" T4Q"ldwo0 tVmL4j04 <br /> �uo�l7a,?Jo suols+no� I u4!Iesuadwoa sjvXjo�v+®�oj�olgns etuooeq p{noUs <br /> 1�1 aajue pueYd�ldo}ll��18�Sfd.�a�4iE j@ Alf A1�i�og�deul g06�Q!LQE�WE�fFR�t� P <br /> ul uosr�ave an°ddui�r�oiai�tealn lacert ate ofa onlLA sent to se°If�in re foroworBWJ°pad ayt ul 38ya ;IU$°I vid for by <br /> ftuc#�Nd41;Ct10egnce of the work for whickers' ccim1I <br /> �it 'isue . <br /> :gig s qW u dgiiod ue jamec <br /> X_ I have and will maintain workers' compensation in,,s,�ranee, as�� �S� dD�� �9 s�lflt Lab r Code, <br /> R CfaQasa�de,obtti b M6NwWgflh� fi'(tt9s 'is'� <br /> apo09�q>t>'f �4�Abs�B p9l9��4%Wjinboi se'eouej Sul u0yesu o, 81, + iur l '®ped'p e <br /> Carriefpenssl sl Iluuad slut►pigm-104 )VOm ayt 10 eou 1 gad eq;io; 'apo0 Joq'I Q4140 0M U011009 <br /> Aooj Pepinwd se 'uollesue ujo ute utCLU M ue 9ney l <br /> I certify that in the p erformanje.01 Ili 19 ! '���3' ii '1t,i8a te�eda Ru3t�"o rson in <br /> sublet to the workers' compensation laws of California, and agree th t if I <br /> should become subject t j5j � yi )q8omtion 3700 of the Labor Code I shall <br /> forthwith comply with kuwl WP <br /> 3 Date: Signature: <br /> J auieu polulid <br /> lJ :a m <br /> � ri ted Name: f <br /> ��S <br /> WAR I ECURE R COMPENSAT ON C V �� D1 JECT <br /> AN.-EMP, OY€R AIQ YB1H'Wt4I9ES UP T DARED Ad D OLLARS <br /> ($100,000.), IN ADD 10 O HE OST OF COMPENSATION,INTEREST,ATTORNEY'S FE�FSJUAN$9&W S AS <br /> PROVIDED FOR IN SECTION gpmpag Am pue apo0,su016'se10a8 Pue <br /> uolswfl Jo(OOoL uo']ae.S 4iv^Igulauauauav�) B�atde4010 sC�olslnad egI�apun pesuaoll we l IBtll use�(ge�s4 I <br /> Y 1 <br /> 57I icAnsee�e�cFre representative), h reby <br /> authorize c,e G� c <br /> CU <br /> 7 I t7 d <br /> to sign this-San Joaquin County Well P it un erstarl �F itM5VC6lMr£3CWal d for <br /> -#2iS 11M vY oI rvYOhl <br /> L J <br /> one (1)year and is limited to the work plan dated Qn th <br /> luswalddng uolltallddy 3!uu,d lipMAt ilufl s,a RAg% M"§i8pjjKCgA*m'o0 umbeor ueg <br /> Z0 3 d Np1>001S 3VV HiTTL9b66Z ET:9T I00Z/S0/T6 <br />