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'=ROP1 -'1,;TER DEVELU •r1Er,IT 91F FG2 1592 1900,0�7 '- 0'7:0c:� #Se F.02!02 <br /> TU•N-12-0E] 05 :03 F171 THE )UKI.:t (,HUUH IN'- <br /> :ft ,_;`1E�aL 11:16 zeya�'�.a?3 FIFTH FLl1UR PptiE 03 <br /> San ,oaquin County Envirrinmantai Healtn!yeryiCes, Unlit IV Well Perrnit AppllcaiIon 6upplerneiit <br /> JOB ADORESS: l(0-1 l� POLP� N� F--o PERMIT SR#: _ <br /> LICENSED CONTRACTORS DECLARATION <br /> i I h.erria/at`-that I am ricenadd U.'ok'tre p•avls,cns of Vo. nirncirg w th, 3t;liCn 7000) 0 nlvi.si:n <br /> 3 of the &rai.ness and Profess ons:�oJe a,,J my ce-3e is r full bre'ani effect. <br /> 283326 Expiraton Oats' 6/30/00 E <br /> 6/13/00 +�nF.�Ct The water Development CorporaL'lon <br /> Cate _..� <br /> District Manager <br /> Printed name: Tom moreland <br /> WORKERS' G0MPENSAT10N DECLARATION <br /> hereby e`l,'r i UrydCr ponaity C1 pe!jUry ore V,he fallowing (CHECK ALL THAT APPLY) <br /> have a-d will r-neinteir,a Gertifp7-are of torsed:to self-!nsVre for worker carT%rensation. as pr0vided for _v <br /> $octicn 3704 e!the LaUorCod a.for the perfo'marlce of the work forwrion this Farr-11's Issuer. <br /> I X I have and will maintain A,o-Ker5,t4�per3atip inairance,ab regVjr`Qd by Section-1731 of the LeSa Code <br /> f.9 <br /> the pertflrinsrca of the war c hr which this Prmit;s issued My`h'4rj,, q" Ps^,dt Orl insurance <br /> cam-and pol'ey nurrbers are: <br /> Intercargo I.19tirarice Co. policy Number; WEC0000199 <br /> c <br /> erti`f r'ict iri the pe^,`ornwGi: of the woert fQ,.4h`c'n tri Q pormit is issued, I sr.a! not emolr>y wy person <br /> any manner so 85 47 btt0e!e 6UbjeCtto The'rrUrkars'zpmpensalion :dw9 nr CRllhmie, enG egrPq(hat if I , <br /> Ell ould become zuq qct to the wprkers'cornpensoticr,provisions of S6ctier< 3700 of the Lm>7a ��a�, ser: <br /> fOr`hw lei comply wish those provls ani.0 �,� /n) <br /> n13/0mcure: �_ --•— -.._.__�__-_�— <br /> Date---,-- /- 0O Sig <br /> ` Printed Name: 2:��effrey T). Morgan _. ...`.,..�-- <br /> WARNING:FAILURE FQ SEGUFtE V�QRKER3'COMPEN5A7;QN C0vCRAr3E la UN'.AWPUL,ALUD 6 il1EL SUBJE�t <br /> AN EMPLOYER TO CRIMINAL PENALTIE9 AND CIVIL. ;NES UFS TO ONE HUNDRVED THG05AND DbL'k,AR$ <br /> (5100,000.).1N ADDITION 7o THE COST OF COIYpE NSATION,INTERE,57,ATTOMNEY'9 f CES,AND DAMAGES A8 1 <br /> pROV1pED FOR IN sECTION 3708 OF THC LA151QR ODS. <br /> I C-6711consed authorized rupresentasve),hereby <br /> AU erixc MDavid ProvanCe <br /> Mr.• — — <br /> to sign this Sar,Joaquin CourAy Weil permit Application on My aoha!f. t u.r d�rsund�!a aUthonzs!ia,Is valf0!u <br /> one f t esr sed,¢IIT:Fad to tho work ciar,dated on.the fr nit page of thI3 <br />