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08/17/22005 15:32 FAX 916852911A Geocon Consultants Z002/002 <br /> 05/02/2005 16:09 209466 j3 FIFTH FLOOR PAGE 03 <br /> San Joaquin County Environmental Health DeNrtment Unit IV Well Permit Application Supplement. <br /> ,JOB ADDRESS: PERMIT SR#. 4- 3 S <br /> 36 s6 <br /> LICENSED CONTRACTOR DECLARATION LCD . <br /> hereby atfirrn that I am licensed under the previsions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Easiness and Pruras$ions Code and my Ileense is in full force andeffect. <br /> License#t �( ✓Ga Expiration Date: S-3 1`100 <br /> 9 <br /> Date: d -I metract r. �_.G 1�O-Akv,v,-CCx`Lt VA <br /> Signature: Title: Secye' uv 4 <br /> Printed nanw._ _ E lev�y��A00 A kia <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the folk wring declarations: (CHECK ALL 71iAT APPLY) <br /> _I have and will maintain a certificate of consent to self-Insure for workers'compensation, as provided for til: <br /> Section 3700 of the Labor Code,for the performance a the work for which this permit is issued. <br /> X I have and will maintain workers'compensation insurance,as required by Section $700 of the Labor Cad--. <br /> for the performance of the work for which this permit is inured. My workers'compensation insurance <br /> owner and policy numbers are: <br /> Carrier: J"V.k- y u"UL Policy Number.._ .i h606tz-_')�C-, <br /> 1 certify that in dm performance of the work for which this pet nh Is issued, I shall not employ any person in <br /> any manner so as to be come subject to the workers'compensation laws of California, and mgrs®that;f 1 <br /> should booon*subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provlalons. <br /> Date: i il � Signature: uVIN <br /> Printed Name: (aim � >L A ti �0 <br /> WARNING;FAILURE TO SECURE WORKERS'OOMPENSATION COVERAGE IS UNLAWFUL,ANO SHALL SUPJECT , <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION,INTICRESr,ATTORNEY'S FEES,AND WWAGE9 AS <br /> PRovmm) FoR 1N secTION 370 OF THE LABOR CODE. <br /> (signature ofC-07 Ilcensad authori>wsd t*preesnv1Hve), <br /> hereby authorize(print C�nn1v1� L�Br�bZ) <br /> t name) � <br /> to sign this San Joaquin County Well Permit Application on my behalf! I understand this auVmrtzation is valid for <br /> one(1)year and is limited to the work pian dated on the front page of this app0oatlam <br /> 1-29-021 MI ,. _J <br />