Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> .T <br /> JOB ADDRESS: �, ,�(�� 1 � "� PERMIT SR #: <br /> LICENSED 'LONTRACTORS 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#: 720 04 Expiration Date: 4/30/2020 <br /> Signature: I !r <br /> I Title: President <br /> -- -- - <br /> Print Name: Karli Renae Stroing� Date: 1 1 C1 <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 /> 13 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 /> 1 certify that in the performance of the work for which this perm is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compens tion law of California, and agree that if I <br /> should become subject to workers' comp`nsation'provisions Section 3700 of the Labor Code, I shall <br /> rthwith comply with those dcvisions. <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 Karli Renae Stroing , heCauthorize Nc"c iH1' <br /> Name of C-57 Ltcenspd Authonzeo Represantahve Pnnt Name of Authonzed Agent <br /> to sign this San Joaquin County Well & Boringlic on my behalf. I understand is <br /> authorization is valid for one yea �ndL�is li t d to th dated o#the front page of this application. <br /> gnature o C-57 Ltc zMRTp.iint- <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />