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ail <br /> q Ej5 ( 24 ( 2002 11 : 21 20�4671ta 1 n AGE SIOCKTUN 1 f'AGL 0.2/ 1)! <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> '11H) Pacific Ave . Stockton , CA q � <br /> JOB ADDRESS : JW PERMIT SRN: <br /> U/w' ;tr L r <br /> j 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 end effect . <br /> License #: C57 552198 / Expiration Data; 06 / 30 /03 <br /> Dale: 2 r}nlra¢tor' Wester - trate Ex lorat: ion <br /> i gnafure: TlOo: General Manager , <br /> Printednamp:/ on D .;� J sen , Jr . <br /> ORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-Insure for workers' compensation , as provided for by <br /> ^ Section 3700 of the Labor Code, for the performance of the work lar which Ihis 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 policy numbers are; <br /> State Compensation Insurang ryAumber. 15697811 -02 <br /> Carrier: ollc <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 3.700 of the LLabel <br /> forthwith comply with those previsions. <br /> Date: 05 /24 /02 Signature: -; <br /> Printed Name : , <br /> Gor/3on..D , 'aerls <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTI�ANO CIVIL FI Es VP 70 ONE HUNDRED THOUSAND DOLLARS <br /> t61 oa,000.), N ADDITION TO THE CO T OF COMPENS ION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDr2D�R 1N SECTION 3706 O,FTHE LABOR C E. <br /> i <br /> -T jai0nature ufC-57 licensed authorized representative), <br /> hereby authorize (pri_ armi) I ' .� . L <br /> lbser/ian this San Joaquin County Well Permit Application an my behalf. I understand this authorization Is valid for <br /> one (1 ) year and In limited to the work plan dated on the front page of this application. <br /> 1 -46021 MI <br /> E ' d BbSO - ELE ( 916 ) X31s3m daT : aD ao t• a ReN <br />