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Data: <br />Signature: <br />Printed name: <br />Contra or . Wat r Develo <br />President Title: <br />NO.917 <br />ltI002 <br />DG/2D/2D02 12:27 GEOLOOP DRILLING -> 19168610430 <br />03.10/.02 F 01 : M 1 V16 861 0.130 SECOR-SACRAMENTO <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement 7 <br />7f70 24 3/ q-0 , <br />JOB ADDRESS: 4i 3`../ 4/ W../i4-tedpo PERMIT <br />5 'fac!+or1, 4 <br />LICENSED CONTRACTORS DECLARATION (ICS) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing With Section /000) of Dfvislon <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License* 2 8 3 3 2 6 <br /> <br />Expiration Date: <br /> <br />(signature erfC-57 licensed authorized representative) p <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following deolarations: (CHECK ALL THAT APPLY) <br />(have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />x I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: McGee Th <br /> <br />Policy Number: WECO 0 01 4901 <br /> <br />- I <br /> <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 if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Da te: 01/20/02 Signature <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 />(Si 00,0001, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />- <br />•••• <br />hereby authorize (print name) <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br />one (1) year end is Ilmftodulo the work plan dated on the front page of this application_ <br />517.2000 I MI