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JUL-02-2002 14:26 FROM:PRECISION SAMPLING 5102374575 TO:650 691 9837 P. 1.3 <br /> 96/192992 14:Yy 2S9a6�:i� <br /> it Irl r6.uuc rl nr_ u <br /> San Joaquin County ErtWlMnMerttmi Health Sarvic rs.Unit IN Well Parmit Appllcadon Supplement <br /> JOB ADDRESS: qq 1 1� � STUC PERMiT SRO. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i hereby affirm that I am ficansed under the provisions of Chapter il(cornmencina with Sectlon 7000)of Division <br /> 3 of the Bushman and Professions Coda and my license isin full foto and effed. <br /> Lkensa*: 63 6,j aL"7 eacpiration Oates ! I o <br /> Date: Contractor �{4.i S b�., �'���-U <br /> Signature; , <br /> Tith �e.''q <br /> Printed name- �-"- <br /> WORKERS- COMPENSATION DECLARATION <br /> I hereby affirm under penally of penury one of the following d0018rations. (CHECK ALL THAT APPLY) <br /> _I hairs and will maintain a oenfteta of consent to self Insure for workers'compensation.as proOded for by <br /> Section 3700 of the Labor Code,for the performance of the work far whlch this permit Is Issued. <br /> I have and will maintai <br />