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01/09/2006 14:50 5102374574 PRECISION SAMPLIS PAGE 02/03 <br /> San Joaquin CountyEnvlronmental Health Department Unit IV Well PcrmitApplicatioorl Supplement <br /> JOB ADDRESS:IW 6j, 62V4 PERMIT SW 0(4 s <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 Professions Code and my license is in full force and effect. <br /> License# � Expiration Date' I ?JI <br /> Date: 0( on or: Y GIGiIDIJ ��,j n/��LIf �lia �1(i. <br /> Signature: Title: <br /> Printed name:/ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally of perjury one of[he following declaratlons' (CHECK ONE) <br /> I have and 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 /> vI have and will maintain workers' rompensatlon insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which[his permit Is Issued. My workers'compensation insurance <br /> carrier and Ipolicy <br /> numbers are: <br /> '1 l{f`11!(�n�t I <br /> Carrier: J{ l�1`�r�1 7V 1 Urry Policy Number;_ WG2'g�l �'f'?33� ' o Z5 <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 I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions <br /> Expiration Date:�Signature: —� <br /> Printed Name: ( b <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SIiALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),1N ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUT A O R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, X N (slanatara oM-.ri7 licensed authorized representative), <br /> hereby authorize(print name_1l rk ) 91,A d. <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one 11I year and is limited to the work plan dated on the front page of this application. <br /> 8-29.021 MI <br /> 13H 29-02001 <br /> aR2/OV <br />