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RVg 17 2005 9: 33AN Water Well Technology, In 916 480-0839 P. 2 <br /> FROM Grourd Zero Analysis PHONE NO. : 205 338 91383 Aug. 17 2005 09:12AM F6 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application?S,upplement f <br /> JOB ADDRESS: Wr7 eV, wrc-Sor►J WA%j PERMIT SRA: J �! <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that t am licensed under the pravisions of Chapter 9(commencing wit:n Section 7000)of Division <br /> 3 01he Business and Professions Coda 2nd my license is In full force and effect. <br /> License#: 7,311-33 Expiration Cote: o- 1 f 3 1 too -► <br /> Date: g ' 1.7 "D Contract r: W %,rgC. (A)ZLL TLed&�e4..4&r _TNe <br /> Signature: Title: AAA i <br /> Printed name: RO 13aElLT -T- Gu r9 nory n j <br /> WORKERS' COMPENSATION DE=CLARATION I <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> have 2nd will maintain a certificate of eonsent to self-insure for workers'compensetion,as provided forby <br /> Section 3700 of She Labor Code,forte 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 of the Labor Code. ! <br /> lfor the petformanee of the work for which this permit is issued. arty workers' compensation Insurance <br /> carrier.and policy numbers are: <br /> Carrier• S7'/9rAV AiWAJo� Policy Number: J_4 9 •� <br /> I certify that in the performance of the work fcr which this permit is issued, I shall not amploy any person in <br /> w any manner so as to become subject to the workers'cornpensatior laws of California, and agree that if <br /> should become subject to the workers' compensation provisions of Se 3700 of the Labor Code,1 shall <br /> forthwith comply with those provisions. <br /> Date: 8 '- / 7 Signature: <br /> JJIV <br /> Printed Name: 0aA A-T <br /> AARNING:FAILURE TO SECURE VJORKERS' COMPENSATION COVERAGE IS UNLAWFUL,ANO SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARS <br /> (S160,000.),IN ADDITION YO THE coST OF COMPENSATION,INTEREST,ATTORNEY'3 FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTIO 706 OF THE LABOR CODE. <br /> I (signature oFC•57licensed authorised representative), <br /> hereby authorize(print namq)$ ' act RY 5--rA H L4 GNOU10ia =ARo A y Sr s <br /> to olgn thla San Joaquin County'Nell Parm+t Application on my behalf. I understand this authorization Is valid for <br /> ons(1)yparand is limited to the work plan dated on the front page of thiC application. <br /> 1.25-02 1 Mi <br />