Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: y� �� PERMIT SR #: <br /> Ca <br /> Lf N ED 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 Drilling, Inc. <br /> License#: 720901Expiration Date.4 /30/2020 <br /> Signature: " Title: Presid nt ' <br /> Print Name: Karli Renae Stroing Date: , r <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 the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject toft w rkers' comp sation law of California. and agree that if I <br /> should become subject to workers' compensation provisionof Section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions. <br /> Signature: t <br /> um:� �1'11!Pli <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, Karli Renae Stroing hereby-authorize <br /> Name of C-67 Licensed Auth,r d Repre—lutive n Na of uM.- Age., <br /> to sign this San Joaquin C unty Well &,Boring ermitApplication on/my ehalf. I nderstand this <br /> authorization is valid for on y ran s lipii ed to th wor plan dated oti the ront page of this application. <br /> (, <br /> '� II f <br /> � i <br /> ig azure of C 67 0.11VT47 e <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />