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_ X001 <br /> 09/02/2004 THU 12:11 FAX <br /> S,p , 2 . 2004 1 : 12PM tiS.r,ht Env1ronmental 822-6152 Ida .4} } 6 p . 2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION UD) <br /> I hereby affirm that I am lleenood under the provisions of Chapter s (commencing with Section 7000)of Division <br /> 3 of the Businese and Professions Code and my{[cellae is in full force and effect <br /> License M Expiration nate, <br /> Date: Uff I�e� �Coontractor: v _ <br /> Signature: �vY ` �/t Ate' Title; <br /> ii <br /> Printed name: f L1 r 1!i c l�'ca��' <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued_ <br /> ✓ I have and will maintain workers' compensation insurance,as required by Section 3700 of the Labor Godo, <br /> for the performance of the work for which this permit i%issued. My workers compensation Ineurance <br /> carrier aV pollcy nuers are, D <br /> Carrier: Polioy Number: D <br /> i certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that K I <br /> should become subjeCt to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply ith t ,1ose.provislons_ <br /> Expiration Date: 1 iJ Signature: bggI <br /> Printed Name: \h LUN <br /> WARMNG:FAILURE TO SF-CURE WORKERS'CWYIPENSA nON COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO 0144.HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION To THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF TLib LADOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> {signature ofC-67 iicensca autharlxed representative), <br /> hereby authorize(print name) ' <br /> to sign this San Joaquin Colliity Well Permit Appilcatlon on my behalf. I understand this authorization is valid for <br /> one(S)year and is limited to the work plan dated on thr,front page of this applicatian. <br /> 8.29-02 1 MI <br /> PED 29-n2-001 <br /> 913C/2M <br /> 09/02/2004 THU 11: 56 [TIC/Rx Nci 69361 91002 <br />