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I he <br />3 of <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: PERMIT SR#AA <br />JOB ADDRESS: c ; kJ Witscm (Ay PERMIT SIRit: 6/4/7(J0 u a 27q 3O5 574 <br />N.57 -e) las <br />Li algraRgatATTMIMEWADriatOr d <br />sion <br />((vs -1 1 /3 /ioei _Axitithsosit414e: <br />t ard% V n griwhegh%%i§ ia f ct. <br />e4lv aftimf ate licereidii&iergyi rcigq?onnss q NR(AlgeA 'iwgpcis.106603QhWgiaivi <br />I. <br />Lic net&ifis. <br />'if • <br />Tiligti: <br />144 a r 6det_ cl e <br />D EC LARATIONRiPSIII'EwMLWERTS <br />I he eby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I hi/e and will maintain a certifcate of consent to self-Insure for workers' compensation, as provided for by <br />I ha vSatKirKil/ 00 aifItitinlitt lizertikalatefarf toe peetotrtta eaftifi kJ* MO (QtYfti**14rriligtiki§tiwegis provided fo- by Sectio.,-1700 of the Labor Code, for the performance of the work for which this souermit. is issued. _LA have and will maintain workers' compensation insurance, as required by Section 000r37 the or Code, <br />I havt901k1PAfffIMAkISR1487RegrUctcrl'044VbrilW-Aii8u, ri6MYEA,r MfcRIIPOCJWIRrebrabor Ccde, for thre(91119;14EYcfPIFIlbnrirTOr which this permit is issued. My workers' compensatioLijnsurance carrearderlircil p o I tnitiy..? are: Policy Number: a e_12J ) g c:2 .,(7.— <br />C rrOfr-----• • Eltitilititisrililfrattflssued. I shall not employ any person In <br />any manner so as to become subject to the workers' compensation taws of California, and agree that if I <br />I certglyckila tfkiicahlEIDLL9601.310 0%40103W:din* ntPrOziortetcitSectiROTW-4100tti-gi34151g9441-4 if on in any rfcatttritithansimptpqdtecthusequbAsibtts•the worke s' sensation la s of lifornia, and agree that if I hould bec <br />fiNfAinith r <br />024rhernpil;rs'tucroem: pens ions kon 0 e Labor Code, I shall <br />POMilAkitia!: Date: <br />WARNING: FAILURE TO SEORE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINX.rilEtil/ALAIIEBIAND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />WARIMBABRILEINETITICSEIRRIRRAOKINKRI TION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />, • • rd A 0 T <br />AN EMPLO E - TO CRIMINAL IF'aL;i1g AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (kl 03,000.) NSATION,Axwbewifahig.crztEmadeitigamari* AS y OR IN SEC ON 370C or TIIE LABOR COD, ' <br />r//lv/ <br /> <br />5f1,11cuntfeastaiutthitiautimellaelisierfttielitliOittreby <br /> <br />I. • • I. . • • I <br /> <br />auth06610.(ayear and Is limited to the work plan dated on the front page of this application. <br />to si <br />ion Is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />5-17-2000 I MI <br />Dat Dat <br />gorge ure: <br />Pri d tediggfii@me: <br />_ <br />:r : a a : a a • mu. • • • • . • <br />hereby authorize (print came) <br />, t "1 ‘.*1 <br />AUG 09 2002 11:29AM Hl LASERJET 3200 <br /> P.1 <br />ue ttits2 11 2094G 33 <br />FIFTH FLOOR <br />PAGE 83