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05/18.J09 08. 41AM All Well ( 4donment 530. 644.1439 P.02 <br /> Received Fax: 05/15/09 11,28kiyax Station., All Vx;.1 Abandonment p,00 <br /> E San Joaquin County Environmental Health Department Unit IV Welt Permit Application Supplement <br /> J013 ADDRESS. / 1930 , . 6 ���� PERMIT SR#: <br /> LICENSED CONTRACTORS C11ECLARATICN (L DY, <br /> i <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 is in fill force and effect. <br /> License ..Expiration Date: - <br /> Date:M Contractor <br /> Signature: _Title: (D r <br /> Piloted name: rN <br /> WORKERS' COMPENSATIO 4 DECLARATION 1 <br /> I hereby affirm under penalty of perjury one of the following de.iarations: (CHECK ONE) . <br /> —I haus and will maintain a certificate of consent to self-ins ure for workers'componsation,-as provided for <br /> by Section 3700 of the tabor Code,for the performance a.'the work for which this permit i8 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 work for which this permit is iss jed. luny workers' compensation:insurance <br /> carrier and policy numbers are_ <br /> Carrier 7 _ r~ _/J� Policy Aurnber:.66 /`7000 --,---)WR <br /> I certify that in the performance of the worn for which this permit is issued,t shall not employ any person in <br /> any manner so as to become subject to the workers'comt ensation fawn of California,and agree that d l <br /> r I should become subject to the workers'compensation provisions of Section$700 of the Labor Code, I shall <br /> forthwith comply with those provisions. . <br /> Expiration Date: /2 ' j n a1 Signal -' - <br /> Print ante: y r <br /> R <br /> WARNING,FAILURE TO SECURE WORKERS'COMPENSATION t:ovERAGE IS UNLAWFUL,AND'SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL.FINES UP"O ONE HUNDRSD THOOSANU DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,IN":'EREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR II+I SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTlOER N C�67 SIGNING PERMIT APPLICATION <br /> _(sit;nature ofC-57 licensed authorized representative), <br /> hereby authorize(print nates) . I ( JYIC. <br /> l to sign this San.Joaquin County Well Permit Application on my behalf.-I understand this authorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front pal,ie of this application. <br /> 8-25.02 t MI <br /> IM 20-02-001 <br /> y <br />