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m.o <br /> FROM :ResonantSoniclnternationalmmoI FRX NO. :5306682429 '"fr. 13 2005 12:44PM P2 <br /> Apr. 12. 2005 11 ;37AM ADVANCED GEO �— <br /> No. 0101 P. 2 <br /> Iowa *a) l3, l� f'is <br /> FJOE3 <br /> aq"In County Environmental Fleeli Department Unit N Well POrmlt Appl/l�tatlonLSupplement <br /> DRESS' IyItI�I Af �p^ R PERMIT SR#; 7/07 <br /> LUD) l C'4 <br /> LICENSED CONTRACTORS DECLARATION (L,CD) <br /> j I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Buslness and Professions Code and my Ilcsna@ is In full force and effect. <br /> License#: Z 3 <br /> Expiration date: <br /> 1 Date; I / Contractor. <br /> Signature: sem,_ h- TItJe: <br /> Printed na <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ONE) <br /> i <br /> I have and will maintain a certificate of Consent to self-Insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code;for the performance of the work for which this permit is issced. <br /> XI have and writ maintain workism'compensation insurance,ae 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 /> Carrler: S//{e_ f...,.�.,,,L _,Policy Number. <br /> I certify that In the performance of the work for which this permit is Issued, I shalt not employ any person In <br /> any manner so as to become subject to the workers'compeneatiori laws of California, and agree that if l <br /> should became aubject to the workers'compensation Provisicns of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Data: I OY Signature: <br /> I <br /> j . Printed Name: r_.,.l r <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT i <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF TOE'LABOR CODE, <br /> AUTHORIZATION F R PILIHIER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature Di 11censed authorized representattva), <br /> hereby authorize(print na ) rA Cyo,//�R <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this atithorrzatlon Is valid for <br /> Lone it)year and;.limited to the work plan dated on the front page of this application. <br /> B-29 r 1W <br /> E'fm 29-02-001 <br /> 6r..1,N <br />