Laserfiche WebLink
10/02/01 TUE 10:39 FAX 1 91991Kl 0430 SECOR-SACROIEFTO 0 002 <br /> Sent By; Gregg Drilling & Testing, nc. ; 925 313 0302) Oct-2-00:22; Page 212 <br /> aV YYl Y'fJV �tC.(at-SAB 0002 <br /> San Joaquin County Environmental Heatth SeNIC98,Unit IV Well Permit AppliccatOorL5�rpplemept <br /> Z3 � -5 L771�oo U <br /> JOB ADDRESS: Z 3S'fa •�vi o tf6491" pERMIT SR#: 062,7609 <br /> Z 3 �� 5 2�rmboa�c <br /> 602,7-6 !/ <br /> LICENSED CONTRACTORS DECLARATION QQJD <br /> I hereby affirm that I am iioensed under the provisions of Chapter 9(commencing with Section 7000)of Divislon <br /> 3 of the Business and Profosslons Code and my license is In full force and effect. <br /> License& Gs 7 YS.5/Gf' Expiration Date: 97/l-M//Q : <br /> Date: /0 Contractort✓�je &Wj�ij;t !t7&-e-.6 <br /> Signature P � _ Title, saDrDldaaa�' <br /> Printed name: e/' maC�' <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 malntaln a Certificate of Consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the penormanne of the work for which this permit is Issued- <br /> I have and win maintain workers campefteation Insurance, as required by Section 3700 of the Labor Cada, <br /> Tor the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrion/qb! we Pottery Number: Wb U1bl�C Y40 <br /> I certify that in the performance of the work for wnich this parmit is Issued,I shall not employ any person in <br /> any manner so as to become subject to the workers'compansatlan laws of California, and agree that if I <br /> should become subject to the workets'compensation provisions of Section$700 of the Labor Code, I ahau <br /> forthwith comply with those provlsions. <br /> d f A <br /> Dow:l /D/ Signature: �L� /116/Rljr( <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORI(CRS'COMPENSATION COYER46E IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EWpLDYER TO CRIMINAL PENALTIES AND CfVIL FINES up TO ONE HUNDRED THOUSAND DOLLARS <br /> a,00D. FOR N tTIONlTO THE COST OF 3706 OF THE LAHORON,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> pRt 0 <br /> CODE- <br /> 1-1-nature ofC.97 llosnaad authorised reprevantetbey <br /> hereby authorize(Print"Me) Ir]/rtlr/1 Cd .. �Ja�f f} ch i4rtor <br /> to aIon this San Joaquln COU"W 01 Pkernitt APPlt ration on my behalf. 1 undarstand this euthorization is valid Ter <br /> one(1)year and Is lirohed to the work plan datad On the front page of this applieatlnn• <br /> 5.17.7Da0/MI <br /> I <br />