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RECEIVED <br />1 A 7008 — <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental, <br />ONE <br />JOB ADDRESS: PERMIT SR # <br />DIVIRN ILALt n <br />pE9m117SEIVICES <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the Business and Professions Code and my license is in full force and effect. <br />License #: ()()E LI /lb xp Date: <br />Date: 7/ I/AA Contractor: AleLl 0 r-w ers6_, ggb( 5 <br />Signature: Title: 1. 603.c.,1 E <br />Print Name: L <br />WORKER'S COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br />provided for by section 3700 of the labor Code, for the performance of the work for which this <br />permit is issued. <br /> I have and will maintain workers compensation insurance, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: &IWOtXl Fre eactially Policy Number: <br />MS <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any <br />person in any manner so as to become subject to the workers' compensation law of California, and <br />agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provisions. <br />Exp. Date: q01 Signature: <br />Print Name: ./1/'8-1.r <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensed authorized representative), <br />hereby uthorize rint name) _71/E14.-4, , /1"Vo af ,to <br />sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br />for one year and is limited to the work plan dated on the front page of this application. <br />R/29/02/MI <br />END 29-01 11/5/07 WELL PERMIT APP