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09/ 18/ 2003 11 : 04 191663 CASCADE DRILLIf IC PAGE 02 <br /> 09/ 48/ 2003 11 : 07 20946 . , S Hut SI Ur� IVn <br /> San Joaquin County Environmental Health Pepst'tment Unit IV Well Permit Apoliestlon Supplarne It <br /> JOB ADDRESS: 1� 1 H vI :Lc r PERMIT SRN._, 3S3J <br /> LICENSED CONTRACTORS DECLARATION (!&DjD <br /> ' hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with ;Keceon 7000) of LTvlr+on <br /> 3 Of the Rusiness and Profeedians Coda and my IIEanFe in in loll force and eNact, <br /> License y' CA I �7 L 0 Expiration pate: 107�D <br /> Oats- - C rdrucior: <br /> signstune: Title: ! <br /> � Printed name' <br /> WORKERS' COMPENSATION DECLARAno" <br /> I hereby sf rn under penalty or pMuty one of the following declermtlon3: (CHECK ONE) <br /> I have and will maintain a cartiflcee of consent to self insure for workers' wmpentfslion, as provided fc r <br /> by Section 3700 Of the Labor Coda, for Me performance of the work for which thle pantdt is Issued- <br /> 1 have and will melntain workers' Compensation lrisuraries, as required by Seeflon V700 of the Labor Cale, <br /> for the Performance of the work for which, this permit is issued. My workers' eomparlsatien Insurance <br /> canier and policy numbers me! <br /> G! 4wr >j \ � b1 LW)Q j Poflay Number: 0,yteQ <br /> I certify that In the performance of the work for whloh this permit Is Issued, 1 shall not employ any person in <br /> any manner so ea to bamme suoject to the workers' compe n i of Caflforttla, and agree that.iY I <br /> should becalms suWaet to the workers' compenseltbn P al41 n 3700 of the Labor Coda, I sh III <br /> forthwith comply with those prouialons: <br /> I <br /> Daft: C ��_ alatttlture: <br /> PAnted Name: inck n_ <br /> WAIWINQ% FAIWRE TO SECVRt; WORKERef COMPP.NSATION OO'YERA 1 M UNL WYFML, AND SHALL tN11,1Ek ;r <br /> AN EMPLDTER TO CRIMINAL PF.NALTWA AND We. FINlts UP To CINE NONPREO THOUSlum OOLLARtf <br /> 3`100 x00,), IN AOOITION TO THE COST OF COMPENSA714001r INTEREST, ATTORNEY'S FF bl, AND PAMPA NS A;t <br /> MOV1010 FOR IN SECTION Ase OF TW L %"R *oDrr, <br /> AUTH ION F R GT THAN C-87 3I/3NINO PERMIT AIIIPUCATION <br /> 4 (elgrws+re 0=47 llCeneed auftuu4etl <br /> repreenamM R), <br /> Hereby subleel ea <br /> to sign tnts Sew Joaquin County Wet, Pent! Appllcalloh 9a my be1W f. I undaraLgm iris avinerjeam is Vow fates <br /> .ne (1) Year and is limited to eke wit# pfhn detect grit the trent Paso d tniti appMaatlen, <br /> `L0.iS-0x f MI <br /> G fi . , • <br />