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JAMIUIX10 <br />JOB ADDRESS:- PERMIT: <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />J0BADDRESS:13&&1---- - I —66g� <br />I hereby affirm that �jo S t �00 of Division <br />3 of the Business �tr� r� d?�'�n�iI ease Is iif frJfl o ean" 'ii errzc .�1V `�g- <br />r (commencing with Section 7000) of Divisr <br />!1i�rtffir;Aty�u licensed und�gi#(�fi1 <br />3 of the Business and Professions Code and my license n r J onLcean e _ t. <br />Date (L - C I " n�r� Contractor <br />License 71 / — — <br />i n ,- Wo F�Ki Rei} �T.ION <br />Date:"-�-w <br />e ce entto self-insureorliti;°rti5a`t'�d''��'mnensation <br />nsurance, or ceriifi d. copy ` ereo .(S 3800, Lab.C). <br />Printed name: 0 <br />Exp. Date - Comp nv ��, ' ' ILL . <br />WORKERS' CO I <br />Zl Certified copy is hereby famishedt ations: (CHECK ALL THAT APPLY) <br />�! ►5�el�lY��yui6+p �t1@>'J�1tq�'�15i�i�l� M�ZY�i'�idif I <br />at^dAf°f�lriftr �stit i�t��l ma xoTff�ewor fo`P� ci111si`hlift�1suedvided for t�y <br />I have et <br />Section 3700 of the Labor ode, for e pe <br />or <br />Fil <br />h gction nee n be o Dieted Y th I ` r <br />tmain ol-ker �e5rR1r 1kgri�a{A3en�Ng Lill ams +}fib' Vection 3700 of the Labor Co o ego ersw�P soon Laws�atCaf�omlagGn9li`Iyn4iba4P'rr��4�dflcYri�° <br />i <br />carrier an po�icy num ers are. <br />ate .,e moi, m� T�Idm�er 9-99 "'Al <br />OT1CI�e Pth�tAie��� t�h� v�9vB�iieFRFI��r4t4§�ceF�fht�IksA+�11m>aV�o�i�assin i� <br />ornp'a}r��?gvl�l�ss�gt�o�sr4t Y8`Po�it,sRt I �f��l�c rl� a�t�t�t+lif 1 <br />ecti n 3700 of the Labor Code, I shJll <br />forthwith comply with those provisions. <br />�n -�� Signature: <br />Date: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />DDIT)ON TO THE COST FNSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THELABOR <br />(C-57 licensed authorized representative), hereby <br />authorize <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />v4o�tj-d HVFS : 0 t 666 t —PC—Li I <br />