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06/11/2002 TUE 10:47 FAX • 1gi00: <br /> 16 8 430 <br /> SECOR-SACRA3SENT0 0002 <br /> 06,11/02 TUE 11:20 FAX 1 9 <br /> xa,44-ok <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> 003o zo3, / <br /> Z-3btS 5 Se�iv Fed R �fpERMIT SR#: O <br /> JOB ADDRESS'---'"g'50 O3CyU`� <br /> 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 and effect. <br /> e Lxpiration Date: o/0-3 <br /> License#: G 5 (^ 72 e9 y <br /> f (}OL <br /> Date: Contractor: V <br /> Title: <br /> Sign <br /> Printed name: <br /> WORKERS' 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 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 /> Q1 � K. � <br /> policy Number: 7/3 _S 3 <br /> Carrier: <br /> s Perm <br /> anyrtmanner'no a ptoebecome subjectormance of to thework fworkersor h coimpensation laws of California, and agree that if I erson In <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions_ <br /> Date: Signature: <br /> Printed Name: <br /> AN EMP WANG: FAI TO CRIMINAL PENALTIESRAND CIVIL F NES VP To ONE HUNDRED THO SANO DOLLARSIOMPENSAON COVERAGE IS UNLAWFUL AND SHALL U9JECT <br /> II CDeo F RAIN SECTION 3706 OF THE DITION To THE COST OF COMPENSATABOR ION, INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PRO <br /> 7 (signature orC-57 licensed authorized representative), <br /> I, <br /> hereby authorize(print name) <br /> r�4 �r <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)Year and Is limited to the work plan dated on the front page of this application. <br /> 5-17.2000/MI <br />