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° 005 / 24 / 2002 11 : 21 209457"`^:8 AGE STOCKTON "" PAGE 02102 <br /> V W ' Z <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 4405 Pacific Ave , Stockton , CA PERMIT SR#• Iv ? o <br /> I <br /> LICENSED CONTRACTORS DECLARATION ( LGD) <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 #: C57 552198 Expiration Date: 06 / 30 /03 <br /> Date 2 Contraclgr' Westernrata Exploration <br /> Signature : ! c itis, General Manager <br /> Printednamet Gordon a. Sen n , Jr . <br /> "/)i1if0RKERSCJ� pENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _ <br /> ( 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 for which this 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 Fu4d 15697811 -02 <br /> Carrier: ollcy umber: <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 fifmponsalion laws o1.5;alifornta, and agree that k I <br /> should become subject to the workers' compensation provisions of Sectigdi° 700 of the La Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 05 /24 /02 Signature: , >G .' '�✓ ' �"� <br /> Printed Nama aordoO_]) t tlens t` <br /> WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE Is UNL FUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES VP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.), IN ADDITION TO THE COST ,OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FMrN SECTION 3706 OF THELA OR CODE. <br /> % iislonature 6fC47 ,I1censad authorizad representative), <br /> (eby authorize (print name) I • L <br /> to sign this San Joaquirif ounty nll Permit Appltcation on my behalf, I understand this authorization is valla for <br /> one (1) <br /> year and IgSlrhlteq to It/e work plan dated on the front page of this appNtaUon. <br /> 1 .25.021 MI <br /> i <br /> I <br /> Z ' d BbSO - ELE ( ST13 ) X31S3f1 dzT : 20 ED bZ ReW <br />