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V <br /> lC -P I <br />� 11 <br /> San Joaecsin County Environmental He, <br /> Ith Department Unit]V!Weil Permit AP 11Cat 1D, So — l <br /> JOBAD0R SS: ��ja ' S I ps"}� trr �(�re�� PERMIT SR*: O7u <br /> LICENSED CONMACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed u ,der the prouisiens of Chapter 9 (commencine with Sec5on 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License N: W6 �)2- _ Expiration Date: <br /> �2_� �, <br /> Date: 7/ ontractor. Eri,r i 1e <br /> Signature: �.�( ' <br /> { P,inted name: Ila a ! <br /> unser Pei; t`!%of per':ur1 cne.Di'}'..= .:!""i`iiirg ==rcticrs: Jam;i <br /> j <br /> i i i^.aVe anao-,v!il(^C:n:cln Ce!;P•'=te of cc t to Sea-;i:5.: e "Dr wcncars' CCm Ccr;`:$?IDn, 'r_5 i:rDViU'e <br /> S .!a. :,7 0l7 1,1 rnanc-, 3f the wo , ic,w itch this P-e-n lli,5'$ :.e!E. { <br /> U „ii: ain?a n ,. rcer s -ice, c—e n t ac r C::cc., i <br /> �1 -P:n L'rai, as redUire CV he I <br /> Cr �• 7 cnCP, .:)f ^iD.n Dr dr'riGl^ ttay rm•-'J issUeC -arc, t <br /> r_..• <br /> carner a C Poiic:i numbers a c: . <br /> C mar: =,j9z J Fciica Number: ) gl-7 �",� _ �:C <br /> ; -- <br /> I <br /> 1 C.,.: ii'.ai?.i 2:^•Cc•.Ti is:.. :4C(�<iCr'{JnlCil i JS E.I it is Issued, 1 <br /> I h. p d, i shall ci .. _, sv� _, � <br /> a.^.f iTta':'1er C a ;D C�CC^78 ::DjeC:iD-tie WCfi<er5�CDmpenSciien laws CC 1,21ii C:'i,.c, ct�C HGice`ricZ!i7 <br /> C, CuIC eCCR;C�- �t`ject'.D.the workers'cc mpensat!en orcvisions of C-ec:D T:70 OT`;'. � � S^^;l . <br /> n L-== de: <br /> i ,`Driit`i•11?!7 CCiiipiy with t}?C52 GroYisiD7-i 5, <br /> ' /Y y <br /> sq. nat <br /> t <br /> I Prin.ad Name: <br /> I <br /> WARNING:FAILURE TO SECtIRc-WCRKERS'COMPENSATION COVERAGE iS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), !N ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTCRNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> 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 page of this application. <br /> 8-29-021 MI <br /> t <br />