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PERMIT SR#: JOB ADDRESS: 433 West geotts Ave, stock.con <br />Policy Number: 60°3-7bb().- <br />--I boy° ono will maintain c.rwmc-r.re, rIr cztrinc:s ta i•-•• <br />Q70C1 ef Os. W4•5_ fru' Trim plartnrI1A111-.01 tnewuri ri vyhkjh illi0 Poralit ib /4,4“"44 ' <br />i novo anr1 Will maintain Will keib' COMPOnePtiOn Ir,ourancace required by Slivlinn 37fla of the Labor Code. <br />tor the performance crf tf,u, iceund. MV vverIcOM corrnencatir.“ <br />carrier and policy numbers are: <br />Carrier: 510(te <br />E -1-114{3),1 • Pm, • <br />Fvniration uate: i2-1i / eignatur9p- <br />y„,„„mr.„14 10. se.ourae ort.AiwieunATirtfq CirlVRACI5 UNLAWFUI Atm SHALL SUBJECT <br />(1100,000.), IN APINTION TO THE COST OF COMPENSATION, INTEKES 1, Pt <br />DDAVIriF11 HD{ IN SEL.111J1‘ Jru0 uor 'rife 00C a. <br /> 4 ,21, 1) 1 v l <br />Anat, <br />AUTH I Km roil 0 'VIER THAN C-67 sicNINC PERMIT PPI [CATION <br />Robert Marty <br />hor.by .utnerfrA icrifft flame) <br />to sign this San Joaquin County well ream fwViii•Latilill VII 1.-y b....if. I uetel.retand 0110 2lithOrliatiOn l& valid for <br />one (1) Year' and is limited to the work plan clatod-vit trru ivtt pssz. <br />San Joaquin County Environmental Health Department Unit 1V Well Permit Application Supplement <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />ileitaq orTriti that i nun liosnaod under tho provicionc of e haptor 0(c•nnirtiorsr,ino with Rfinn 701301 of Division <br />3 of the Business and Professions Cede and my license is in full force and effect. <br />10-31-2008 <br />Con rarfinr <br />_ <br />WORKFRS' COMPENSATION DECLARATION <br />nereoy Nei Foci millL,rpcm Jul y .1,....1.e<s6ar..., (1i-4=rue nikir) <br />I certify that in tne performance Of the work for which -this permit 15 issued, i onan not empiqy killy person In <br />ony monnor co ac In harnmA subject to the workers compensation laws of California, and agree that if <br />+rt. 41,a, waeoleane rnmnancption provisions of Section attJU or tne Laoor Guth:), I 41 iefil <br />61.6 LiWetIV: <br />8-29.021M1 <br />ç5 -4a359 Expiration Date: <br />ALL WELL ABANDONMENT <br />I ironse ii• _ <br />Dot°. <br />Signature: <br />Prints-a-name: <br />Title: Vie5itikt— <br />FEB-7-2004 08:14F FROM: ALL WELL ABANDONMENT 1 C530(644-1439 <br />LQ. Lvtiv I. I inrn flU Vifl¼J UCVLII II VillilcilL <br />TO:12094671113 P.2 <br />1LVV <br />t 29-u.t.o.e.21 <br />6/22/04