Laserfiche WebLink
San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1200 Humphreys St PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 pf the California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: V & W Drilling <br />License #: Expiration Date: 16 <br />Signature: I U Title: C L j <br />Print Name: \ V 1� �; Date: <br />WORKERS' COMPEN TION 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 />compens tion urance carrier and policy numbers are: ll <br />Carrier: Policy #: C` I 1!5A d� -IJ Exp. Date: I 0 <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 becom4eEe 'to the wor ' compensation law of California, and agree that if I <br />should become subject to wmpensation p visions of Section 3700 of the Labor Code, I shall <br />ith comply wi those provisions. <br />Signature: �� <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />to sign this San Joaquin Coun <br />authorization is valid for one ve6r a <br />hereby authorize <br />nt Name of <br />@4 Agent <br />g pp y behalfoltunderstand this <br />Well 8, Borin permit Application on <br />d is li ited to th` Work plan dated on a front page of this application. <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />