My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
WP0039114
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
W
>
WEST
>
9501
>
4200/4300 - Liquid Waste/Water Well Permits
>
WP0039114
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
5/20/2019 4:30:12 PM
Creation date
5/20/2019 3:58:43 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039114
PE
4372
STREET_NUMBER
9501
STREET_NAME
WEST
STREET_TYPE
LN
City
STOCKTON
Zip
95210-
APN
08406006
ENTERED_DATE
12/13/2018 12:00:00 AM
SITE_LOCATION
9501 WEST LN
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Scanner
DAfonskaia
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
10
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Manteca, CA PERMIT <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 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: V& W Drill c. <br /> License #. 720 04 Expiration Date: 4/30/2020 <br /> Signature: Title: Presidept <br /> Print Name: Karli Renae Stroin Date: <br /> —.lo/q <br /> WORKERS' COMPENSATION 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: State Fund Policy#: 9115022-18 Exp. Date: 10/2/2019 <br /> I certify that in the performance of thep'thc6mpl <br /> s permit is issued, I shall not employ any person in <br /> any manner so as to become subjeompensation law of California, and agree that if I <br /> should become subject to workers' isions of Section 3700 of the Labor Code, I shall <br /> forthose provisions. <br /> Signature: <br /> Print Name: Karli Renae Stroing <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Karn Renae Stroing ,heaork <br /> ize Condor Earth Technologies <br /> to sign this San Joaquin Coun <br /> tyll oring ll do on my behalf.I understand this <br /> authorization is valid for one y rII d to tn ate on the front page of this application. <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />
The URL can be used to link to this page
Your browser does not support the video tag.