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01/09/2006 14: 50 5102374574 PRECISION SAMPLING PAGE 03/03 <br /> San Joaquin County Environmental <br /> Health Department Unit IV Well Permit Applicatio[nn uppfeement <br /> JOB ADDRESSAL)( PERMIT SR#: � ( t <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provlslons of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Buslness andel Professions Cade and my flcense Is in full force and effect <br /> / <br /> License#'. r� (O i /sq- Expiration Dale,? n�I ' ✓1 bt0 <br /> 01ter Qb Cantraplor I�lot1 6Q// <br /> Signature. _� Titley Q I//E <br /> Printed name: � W <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a cnrflflc;3Ie of ronserit to self-Insure for wodcers'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 <br /> //' <br /> 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 numbers are <br /> r.� 1 ✓', I! �/ �f �/' <br /> Carrier: L.J� Ir ly M, Pollcy Number: <br /> I certify that In the performance of the work for which this permit is issued, I shall not amploy any person In <br /> any manner so as to hecome subject to the workers'compensation laws of California,and agree that it I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those previsions. <br /> Expiration Dater Signature: <br /> Printed Name: L(�JQc VCM LT�� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHAW.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIE6 AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($10D,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 /> �/ AUTM <br /> /��THAN C_57 SIGNING PERMIT APPLICATION <br /> I., ]^- Lnn, // (signature o10-57 licensed authorized representative), <br /> hereby authorize(print name) FI )ret �n ne)o/6.�Q , ., <br /> to sign this San Joaquin County Well Permit,Application on my boh011. I understand this aulhorizatimr Is valid for <br /> one(1)year and is limited to the work plan dated on tlrc front page of this application. <br /> 8-211-02 1 MI <br /> CI ID 29.02 0DI <br /> 6/2210.1 <br />