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1SZ29/2004 12:18 FAX 7073744300 Woodward Drilling IM 002 <br /> DEC 29 '04 10:15 FROM: t _ T-556 P-01/01 F-567 <br /> I <br /> San Joaquin County Environmental Health Departure 110 N Well Pemtl!Application upplgrne� <br /> JOB ADDRESS. Z�,ze� I" PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL[ CQ <br /> I hereby affirm that I am licensed under the provisions of Chapter 11(commencing with Section 7000)of Division <br /> 3 of trio Business and Professions Codia and my license Is in full fbrce and effect <br /> License#; 2 9 Expiration Date: g 31 ?Gds <br /> Cote: I 'Z Z� -7-t �*�f' ,Contractor <br /> Signature. T Us: csnh- - <br /> Printed nares, <br /> WORKERS' COMPENSATION DECLARATION <br /> I haraby affirm under penalty of perjury one of the following decla a llons: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self insurf►for workers'compensation, as provided for <br /> by Section 3700 of the Labor Cotte,for the performance of a a work for which this permit is issued. <br /> I have and will tion insurance.a.i <br /> for the performance of"work for which ntain workers' this permit is la ue 9 Ml <br /> My wored rkers'compensation Laboron 3700 of thG <br /> mpeng tion nsur nte ode <br /> carrier and policy numbers are: <br /> Carrier*. �i(a; policy NLmbsr=2 <br /> I certify that In the performance of tho work for which this psi mit is issued, I shill not employ any person in <br /> any manner so as to become subject to the workers'compel lection laws of California,and agree that If I <br /> should become subject to the workatrs'compensatlon Provis one Of Section 3700 of the Labor Coda, t shall <br /> forthwith comply with those provisions, <br /> expiration Date-10)f Signature: <br /> Printed Nome; <br /> RAQM 16 AND&"ALL <br /> AWARMNG-FAILURE TO N EMPLOYER TO CRIM NAL PONALTIEs AND MCURE PL FINES P Tt ANE MUN13N THOUSAND DOLLAitB(sioo,000.),IN AVDMO14 TO U�ao� <br /> M COST OF OF TFlls LABOR CODE, <br /> INT"EST,ATTORNEY'S Fflis.AN13 DAMAGES AS <br /> PROVIDED FOR IN SECTION 7 <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> slprlatum ofC-a7 licensed authorized representative), <br /> hereby authorize(print nimeL:::� <br /> to sign this San Joaquin County well Permit Appliesuon on my be half. I underatand Min authorisation la valid for <br /> one(1)year and is limited to the work plan dated an the front fag a Of this applleation, <br /> a-aP-03!lYfl <br /> 9HD 29.02.041 <br /> 6!2x!04 <br />