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San Joaquin County Environmental Health Dep rtment Unit IV Well Permit Application plement <br /> X999 W. r10- h�o� � ��f� /2- <br /> JOB ADDRESS:�ZooQ <br /> JOBADDRESS:�Zoo0 w, /.16iu /95(3( PERMIT SR#: DO 'J/o <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Proressions Code and my license is in full force and effect. ✓// <br /> License ar: , �' `.� ;�4! Expiration Date: 176131A, <br /> i <br /> Date (Vaele•c- Contractor 02�r-5:.,.,,, ,.,fS...�:. <br /> Signature: Title: �� �•.•r.�.i..-r RAO <br /> Printed name: c'7<_.v 1n1.'A,,C. -DcmP4 LEE W1N6LeWIC1{ <br /> J <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have arid 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 Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and <br /> ``policy <br /> --numbersare: <br /> Carrier: mil b_ Blurt Policy Number: . 00 n53`-1 -2l 00 L,, <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 if <br /> should become subject to the workerscompensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions <br /> Expiration Dater 0 Signature: <br /> Y/ Printed Name:_ -.%:"r�..., <br /> U <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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'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 /> U, - °---- (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) +it7tJW T�-�OL O t:/ r IZ <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 /> 0-29.021 MI <br /> �. <br /> I'll`y.U:.Wit <br /> r Yn: <br /> P -CI F74,7-Rqq ( r1FG1 2U1111ja Tsa eTE :SO 90 82 oaa <br />