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09/21/2007 16:42 916638E CA5ADEDRILLING y N4. ye« 4PAGE <br /> 8ep, 21. 2007 4:28PM Advanced GeoEnvlronmental <br /> San Joaquin County Environmental Health Department Unit IV Well Pormit Application Supplement <br /> JOBADDRESS: .y qy 7f1oRNi. AmA-0 PERMIT SiR#= OL 10 <br /> mor C/k ci5Ry-F <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that( 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 /> I YO <br /> License#:7 —L�L� Expiration Date 7 <br /> Date: J �� ~� 1 7Contractor <br /> _ Des M <br /> Signaturr±r Title: <br /> �T�- ` _.__ <br /> T-Printed name: _ 1 o h�( <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons: (CHECK ONE) <br /> _I have and will maintain a certlfioste of consent to self-Insura,for workers'compansation, as provided for <br /> by 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'compensator,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 /> caller and policy numbers gar Ie: <br /> Carrier: �JAy ' I"��( d�-` Policy Number Q7eV 531 <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 3700 of the Labor Code, I shall <br /> forthwith comply with those <br /> yprovisions, <br /> Expiration Date: Signature: 1 <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> .),IN FOR ADDITION SECTION HE CO THE OF COMP NSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature OIC-57 licensed authorized representative), <br /> hereby authoriza(print name) rn�p /7jc3e-T MA47 Gq� n/ c tesr.i-_. <br /> to sign this$en Joaquin county Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)yoar and Is limited to the work plan dated on the front page of this application. <br /> 8-2e-021 MI <br /> EHD 29-02401 <br />