Laserfiche WebLink
84/30"2003 14: 58 9255211454 VIRONEX SF P-AGE 02 <br /> 04/29/2008 02: 45 925371 / GEOCON - EAST 13A PAGE 02/02 <br /> San Joaquin county Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Z37Sl 5- �/ ` r-- PERMIT SRO: '1 l3 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 8(commencing Wlth Section 7000) of Dlvl$lCn <br /> 3 of the Business endProfessionsCode and my license is in full force and effect.License <br /> i..J <br /> Licenseev7i:1,�-12l Expiration Date: VS- 3l • O 1 <br /> Date: -•iContractor: \J 1K"O()ex <br /> Signature: � l �lAua"^ T111:18: 6)l rncwa!yR <br /> Printed name: I It Q Arn a�rh <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> Il I have and will maintain a certificate of consent to selbinsure far workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> I <br /> I have and will maintain workers'compensation insurance,as required by Section 3700❑f the Labor Cade, <br /> for the performance of the work for which this penult is issued, My workers'compensation insurance <br /> carrier and policy numbers are: /�,,� 1 ' / <br /> Carrier; r� / _Policy Number: 7/�i�t l� <br /> I certify that In the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that R I <br /> should become subject to the workers'compensaton provisions of Section 3700 of the Labor Code, I$hail <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: Tfhw,, z,� <br /> Printed Nsmei L.0 Ia�(�-.- t�tr►[d(lfi <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (Stan,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> I, QQA, caAi _. (Signature cffC-57 licensee'1d_authorized rapronantativq), <br /> hereby authorize(print name) Q)CK 1JKu$S'C/1 STC <br /> to sign this San Joaquin County Well Permit Application on my beharf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated an the Mont page of this application. <br /> 8-29-021 MI <br /> 6HD 7.9•nJ.-001 <br /> $uvea <br />