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Jun 22 07 10: 40a Fisch Drilling 707-760-3571 P. 1 <br /> FROM Grourri zero Anal� PHONE NO. : 209 838 %83• Jun. 22 2007 09:21RM P2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOSALDRESS: /(46-110' W, lf �b^*MtR �- PERMIT SR#: <br /> ST-4C KT <br /> LICENSED CONTRACTORS DECLARATIONL{ CD) <br /> Lhereby affnn that I am licensed undar the provisions of Chapter g(commencing with Section 7000)of Division <br /> 3 of the Business Q antd�Professions Code and my license is in fill force and effect. <br /> License ttit. 1 J0 R,95 E)viration Date, <br /> ,, 1-,-31 -De <br /> Date: Jn-�.--0'7 Contractor Fl 14 J4 AI LL I IUG- <br /> Signature: Title: Q r7/A)iak. <br /> Printed name: c I d R3U <br /> WORKERS' COMPENSATION DECLARATION <br /> i hereby affirm under penalty of per)ury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers compensation, as nrovided for <br /> Eby 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 reouired by Section 3700 of the Labor Cade, <br /> I for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> 1. Carrier: fiis4Sflf'Ap pans, _Policy Number; (I 060e-';200(0 <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 uo as to become subject to the workers'compensation taws of California.and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cede, I shall <br /> forthwith comply with those provlsinns_ <br /> Expiration Date: Signature: <br /> Printed Name: -DAVID r- .SC-�{ <br /> .WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (4100,000.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC57 licensed authored representative), <br /> hereby authorize(print name),,,�t� <br /> to sign this San Joaquin County Well Parmtt Application an my behalf. I understand this allthortZaUm Is valid for <br /> one(1)year and is limited W the Work plan dared on tho from page of this application. <br /> 8.25A21 MI _ <br /> t7i0 29rti-�`OI <br /> 6rZM4 <br />