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Qj <br /> San Joaquin C13unty EnWronmenUl Healttt Dsparb"ant Unit 1V Well Permit Apptioation Supplerrmant <br /> JOS ADDRESS: PERMITS <br /> LICENSED CONTRACTORS DECLARATION (SCD <br /> I here y I'Mrm that I am licensed under me pmvisions-of Mapter g(CornmerirAV with Section 7000)of DNtsfon <br /> 3 of the SUstress and Professions Cada and my kvme Is In full furca and e <br /> � z&I; <br /> License#: epdate: <br /> Data: Carrtractor � t? �TI{�II <br /> Sfgnat+�Cp: TIM. ffidt <br /> Printrd naMe: r r L( .7X .m <br /> WORKERS'COMPENMION DECLARATION <br /> I herebyaf'f'irm under der persalry of perfirry one of the fallowing declarations: (CHECK UNE) I <br /> I have end will maintain a ceffx8W of cwsertt to seif4ram for woHwr W Gornpermffon,as Providea for <br /> by Set. M 3700 of the Labor Coda.fbr the p&fonwce-of the work tr wlxich tide permit�i rued, <br /> t h and will maintain wt}rltsrs'compertsatkm irtwrance as mquired by Sedlon 3700 Df the Labor Code, , <br /> for Ine performance of the uratic for w"this Permit is IsaUed. My workem'mmperisatlai kwurancs <br /> carrier and path y n mbem are; <br /> Csfrele►��� Policy Number: <br /> I comity that in the perkmmince c f the work for wrIlch this pe"It Is Lssued, I shvIi not employ <br /> any txrson In <br /> , <br /> mavw so as a bei ame"KI tv the yvdrkers'cwVensatfan �Itc <br /> hIms of mia, anti agree fhat.if I . <br /> shovirl become stxdje Ll to the wOrlcers'CemPMS2Gan MmsiQns Of SeCdOn 3700 of rho Ltrcr Code,i shad <br /> fiorttnNltlt oomply with thaw p vAsians. <br /> ��: S3enat�urQ: <br /> Ptinled 1�at�rte: <br /> WARNING:FAII,t7tZF TQ sr;cURE WOMMW GX*pt hSATMN CDVFRAGE eS UNLAWFUL, !1HAL1 <br /> A1Y17 .SUZ EOT' <br /> AN EMPLOY"TO CR1gll+IAi.POIALUM AND CIM�O UP TO(ME WNDR* THD11sIAN i iOlrt.lye <br /> PROt WED IN AD SECT Tp 3 COST OF COMMSATXK iNTERM,ATrORNEY'S FFE%ANo uAAfAGE5 AS <br /> OV1ffGI:O FC1t iiY SECTIpN 37[)G Of�'Lal"CODF <br /> AUTHORIZATION FOR PMER THAN C47 SIGNING PERMIT APPLICATION, <br /> (afgnartore ofC47 fipsr4W aulhod and r,queseatatrval. <br /> pwreby artthofte(prlrrt R3+Rr@ o d - Z'N V t^ <br /> to sign this 30h Jo"uln Conary Wmtl Pwm1tApplication orf 0W behdi! 1 andera#nnd this ri4luon ra vww carr <br /> ants(i)year and rs kmftsd to the whrk pled dated on the fmnt Par"of arta avwkatlan. <br />